Geisinger Health System Anesthesiology Residency Program. Advanced Airway Management

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1 Geisinger Health System Anesthesiology Residency Program Advanced Airway Management INTRODUCTION Airway management is part of everyday anesthesia practice. Major complications are frequently associated with airway mismanagement. Education and training in airway assessment and management begins in medical school and will continue throughout one s residency and beyond. The CA-3 year rotation in Advanced Airway Management is designed to give the resident consultant level expertise in airway anatomy, assessment, and management, including techniques of ventilation for special circumstances. The rotation will consist of attending-supervised education and care for four weeks during the CA-3 year (see schedule for Advanced Airway Management and General Anesthesia rotations). In addition to staff anesthesiologists, residents will also be educated by staff otolaryngologists and pulmonologists. During this rotation, residents will manage the anesthetic care of patients undergoing certain diagnostic and therapeutic ENT, pulmonary medicine, and thoracic surgical procedures involving the airway. The wide range of patient cases, case volume, and case mix at Geisinger Health System will easily give the resident the experience necessary to manage these complex cases, which either involve a shared airway and/or utilize special ventilatory techniques. Residents will also be available and involved with fiberoptic intubation in cases that do not have Anesthesiology residents assigned. In addition, residents will spend time in clinic and in the animal lab with staff otolaryngologists and pulmonologists to gain further knowledge of airway anatomy, airway topicalization, direct and indirect visualization of the airway both in the normal state and in disease states, and emergency surgical airway management. During this rotation, residents will also be involved in the teaching of junior Anesthesiology residents, residents from other specialties, medical students, and paramedical students in assessment and management of the airway. Didactic lectures and case discussions will be presented during daily conferences. These will be provided by staff anesthesiologists, otolaryngologists, and pulmonologists. Didactic and clinical training in resident education will be supplemented by individual one-on-one case discussions, required reading assignments, and experience with simulation. By virtue of these experiences, the resident will develop consultant level knowledge enabling them to provide state of the art care in advanced airway management. The education gained during your rotations in Anesthesiology at Geisinger Health System will be structured around the core competencies as outlined by the Accreditation Council of Graduate Medical Education. Resident progress will be monitored by several methods as outlined in the Residency Handbook to ensure continued progress towards the level of a consultant. Regular feedback will be given to each resident regarding his or her progress. We also seek resident input so that we may continually improve and enhance the educational experience. CA-3 Year Advanced Airway Management Rotation Educational Goals: 1. To enhance and develop consultant level knowledge and understanding of airway anatomy. 2. To enhance and develop consultant level knowledge and skills necessary for the assessment and management of patients who require airway management. 3. To formulate and execute appropriate and safe plans for obtaining a secure airway in both elective and emergent scenarios. Page 1 of 6

2 4. To further develop and expand knowledge and understanding of the innervation of the airway and methods of anesthetizing the airway, including knowledge and understanding of the drugs commonly administered for this purpose. 5. To further develop consultant level knowledge, understanding, and experience in the management of the anticipated and surprise difficult intubation. 6. To further develop and expand the technical skills necessary in advanced airway management, including fiberoptic intubation and bronchoscopy and the surgical airway. 7. To further develop and expand knowledge of surgical procedures involving the airway (including LASER) and understanding the implications for anesthetic management. 8. To expand and develop advanced knowledge, understanding, and skill with special ventilation techniques. 9. To act as a consultant anesthesiologist in airway management. 10. To act as an effective consultant during crisis management. 11. To act as a consultant anesthesiologist in teaching airway assessment and management to other learners 12. To continue to develop study habits that will continue throughout one's professional career. Competency-Based Educational Objectives Please note that these are in addition to the general goals and objectives for the program as outlined in the Resident Handbook. Patient Care The resident must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must demonstrate the ability to perform accurate, comprehensive medical interviews, physical examinations, and review of data. They must make diagnostic and therapeutic decisions based on available evidence, sound judgment, and patient preference. Residents must possess procedural skills and must keep a complete and accurate record. CA-3 Level Patient Care Skills include: 1. performing a thorough and efficient evaluation and assessment, plan, and execution of plan in the management of the airway in both elective and emergent settings for a variety of patient populations, including: a. pediatric patients b. non-cooperative patients c. patients with TMJ disorders d. obese patients e. patients with OSA f. patients receiving antithrombotic or thrombolytic therapy g. obstetric patients h. patients with congenital abnormalities i. patients with connective tissue disorders j. patients with head/neck cancers k. patients with head/neck infections l. patients with head/neck injuries m. patients with facial trauma or burns n. patients with head/neck radiation therapy o. patients with tracheal stenosis 2. preoperative education of patients with known or suspected difficult intubation while addressing anxiety issues and providing reassurance for both the patient and the family; 3. communicating effectively with both patient and family; 4. selecting and using appropriate drugs for sedation/analgesia and airway anesthesia; 5. selecting and using appropriate special ventilation techniques for surgical procedures involving the airway, including: a. apneic oxygenation Page 2 of 6

3 b. side-arm ventilation for bronchoscopic procedures c. jet ventilation techniques d. management during laser procedures involving the airway 6. planning and preparing for extubation to minimize airway-related complications 7. maintaining vigilance; 8. demonstrating critical clinical thinking; 9. demonstrating problem solving ability; 10. maintaining anesthetic record of patient care throughout perioperative period, including documentation of difficult intubation; 11. postoperative follow-up of and counseling of patient, communication with patient and family, and appropriate and timely documentation in medical record: 12. acting as an effective member of the health care team to provide optimal patient care, including appropriate transfer of care; and, 13. developing the following procedural skills: a. appropriate administration of sedation/analgesia and airway anesthesia during performance of awake techniques b. adherence to ASA Difficult Intubation algorithm process c. airway management techniques i. oral and nasal airways ii. supraglottic airways iii. direct laryngoscopy iv. intubating stylettes v. video laryngoscopy vi. fiberoptic intubation vii. fiberoptic intubation thru LMA viii. fiberoptic bronchoscopy ix. retrograde intubation x. cricothyrotomy xi. percutaneous tracheostomy xii. endotracheal tube exchangers xiii. ventilation techniques, including transtracheal jet ventilation Medical Knowledge The resident must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents must demonstrate appropriate knowledge of basic and clinical sciences and mechanisms of disease. They must recognize gaps in their knowledge and promote resourceful development of expertise. CA-3 Level Medical Knowledge Skills include: 1. demonstrating knowledge and understanding of functional anatomy of the airway; 2. demonstrating knowledge and understanding of implications of patient conditions and disease processes (noted above in Patient Care section) as they relate to airway management; 3. demonstrating knowledge and understanding of innervation of airways and techniques for topicalization/airway anesthesia; 4. demonstrating knowledge and understanding of uses, contraindications, trouble-shooting, limitations and complications or the variety of airway devices; 5. demonstrating knowledge and understanding of surgical procedures of the airway and the implications for anesthetic management during such procedures; 6. demonstrating knowledge and understanding of implications of LASER surgery of the airway as it relates to anesthetic management, including a. types of LASER, LASER physics, and tissue effect of LASER b. LASER safety of patient and personnel c. prevention of airway fires i. LASER safety and correct selection, use, and protection of endotracheal tubes Page 3 of 6

4 ii. inspired oxygen concentration and other gases d. management of airway fires: 7. demonstrating knowledge and understanding of the ASA Difficult Intubation algorithm 8. demonstrating knowledge and understanding of special ventilatory techniques for surgical procedures involving the airways, including indications and uses, limitations, trouble-shooting, and complications of: a. apneic oxygenation b. side-arm ventilation for bronchoscopic procedures c. jet ventilation techniques d. management during laser procedures involving the airway 9. demonstrating an ability to effectively teach airway assessment and management to Anesthesiology residents and other healthcare professionals. Practice-Based Learning & Improvement The resident must investigate and evaluate their care of patients and patient care practices. They must locate, appraise, and assimilate scientific evidence and continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to identify strengths, deficiencies, and limits in their own knowledge and expertise, set learning and improvement goals, and identify and perform appropriate learning activities. They must systematically analyze their practice using quality improvement methods and implement changes for practice improvement and should incorporate formative evaluation feedback into their daily practice. They should use information technology to access and manage medical information to support and optimize their own education; and must facilitate and participate in the education of patients, families, students, residents, and other health professionals. The development of effective learning skills and the importance of life-long learning are a primary focus. Residents must appreciate that knowledge in all aspects of medicine in general and anesthesiology, in particular, is constantly expanding. Residents are required to keep current with all reading assignments but are strongly encouraged to constantly search current literature for the most recent developments in our field and to incorporate those findings into practice. The Department is responsible for creating an environment where residents feel comfortable seeking assistance in correcting deficiencies in knowledge or skills. CA-3 Level Practice-Based Learning & Improvement Skills include: 1. keeping up with and exceeding the required reading assignments for the advanced airway management rotation; 2. performing literature searches and analyzing pertinent journal articles related to airway management and implementing appropriate changes to improve patient care and safety; 3. participating in the evaluation of new airway technologies; 4. using information technology, such as information from the electronic medical record, to improve quality of patient care; 5. participating in the daily operative schedule review and case discussion of patients with known difficult intubation and patients scheduled to undergo procedures of the airway; 6. seeking feedback from attending faculty, surgeons, patients, and families and incorporating feedback information to improve patient care and satisfaction; 7. educating patients and families about anesthesia risk, invasive procedures, anesthesia techniques as they relate to assessment and management of the airway; 8. educating anesthesiology junior residents, residents from other specialties, medical students and other health care professionals about evaluation, assessment, and management of the airway; and 9. seeking feedback from residents and other learners and incorporating feedback information to improve the content, quality, and effectiveness of your teaching skills. Page 4 of 6

5 Interpersonal and Communication The resident must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; communicate effectively with physicians, other health professionals, and health-related agencies, work effectively as a member or leader of a healthcare team or other professional group, act in a consultative role to other physicians and health professionals, and maintain comprehensive, timely, and legible medical records. CA-3 Level Interpersonal and Communication Skills include: 1. demonstrating interviewing and interpersonal skills to: a. build the appropriate Doctor/Patient/Family relationship i. exhibit the appropriate behaviors to correctly open dialog with the patient/family ii. utilize the correct methodology for gathering information from the patient/family b. share information with the patient and family c. close the interview with appropriate summations and discussion 2. providing preparation of patient and family for subsequent anesthetic, surgical procedures, and postoperative care, including awake fiberoptic intubation; 3. answering patient and family questions completely and professionally; 4. demonstrating concise, accurate and effective writing skills in written reports and records, including documentation of airway difficulties in the medical record and difficult intubation letters to patients; 5. using medical and technical terminology accurately and appropriately; 6. communicating (using verbal, nonverbal, and listening skills) effectively with patients and patient s families; 7. applying effective communication skills during procedures on awake patients; and 8. communicate effectively with the surgical team, including anticipated airway difficulties, intraoperative management and ventilatory techniques as they relate to the surgical procedure, and postoperative care. Professionalism The resident must commit to carrying out their professional responsibilities and adhere to ethical principles. Residents are expected to create and sustain a therapeutic and ethically sound relationship with patients and their families. They must be committed to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices. The resident must be compassionate, have integrity, and maintain respect for others, be responsive to the needs of patients and their families and society in a manner that supersedes selfinterest, and be accountable to patients and their families, society, and the profession. He/she must be sensitive and responsive to a diverse patient population, including diversity in gender, culture, race, religion, disabilities, socioeconomic status, and sexual orientation. Residents must establish a lifelong commitment to excellence and on-going professional development. CA-3 Professionalism Skills include: 1. interacting appropriately with staff caring for patients in a manner that promotes team cohesiveness and improves patient care; 2. approaching the patient and family in a professional, respectful manner (including attire) that establishes confidence and allays anxiety and fear; 3. developing an awareness, respect, and understanding of the cultural and religious issues of patients in rural Pennsylvania and how these may affect healthcare decisions made by patients; 4. maintaining constant vigilance to protect patient confidentiality; 5. being dependable and punctual in all aspects of one's practice; 6. practicing high quality conflict resolution skills; and 7. understanding the importance of life-long learning as critical to continued safe care of patients and the specialty of Anesthesiology. Page 5 of 6

6 Systems-Based Practice The resident must have an awareness of and responsiveness to the larger context and system of healthcare. They must call effectively on other system resources and work as a team to provide care that is of optimal value. Residents are expected to work effectively in various healthcare delivery settings and systems relevant to their clinical specialty and partner with healthcare administrators and providers to assess, coordinate, and implement changes to improve healthcare and monitor and assess the affect these changes have on system performance. They must understand how their patient care and professional practices affect other healthcare professionals, the healthcare organization, and society in general and how elements of the healthcare system affect their own practice. Residents must coordinate patient care within the healthcare system relevant to Anesthesiology and must incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care that does not compromise quality of care. They must advocate for quality patient care and optimal patient care systems and assist patients in dealing with system complexities. CA-3 Systems-Based Practice Skills include: 1. working effectively with surgeons, pulmonologists, emergency medicine physicians, and patients and families to provide optimal care of the patient; 2. utilizing all system resources that are available to optimize the care and comfort of the patient while being cost-conscious and without compromising quality of care; 3. assisting the patient and family in dealing with system complexities, especially at a time of great uncertainty, vulnerability, fear and anxiety; and 4. identifying institutional strengths and weaknesses as they pertain to airway management and working within system resources to improve upon areas of weakness. Page 6 of 6

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