Competencies & Objectives

The Orthopedic Trauma Anesthesia Rotation at Stanford University Medical Center offers an experience in the care of trauma patients both in the acute and hyper-acute setting. Although the rotation will be primarily based on orthopedic trauma cases carried out during the 2-week segment, the objective of the module is to incorporate the management of trauma outside this defined period to include all trauma cases encountered throughout residency. Additionally, with an ever-aging population this rotation seeks to expose residents to key concepts in geriatric anesthesia, as many orthopedic trauma cases involve patients of advanced age with multiple co-morbidities necessitating careful consideration to anesthetic choices.

Rotation Objectives

The Orthopedic Trauma Anesthesia Rotation at Stanford University Medical Center offers an experience in the care of trauma patients both in the acute and hyper-acute setting. Although the rotation will be primarily based on orthopedic trauma cases carried out during the 2-week segment, the objective of the module is to incorporate the management of trauma outside this defined period to include all trauma cases encountered throughout residency. Additionally, with an ever-aging population this rotation seeks to expose residents to key concepts in geriatric anesthesia, as many orthopedic trauma cases involve patients of advanced age with multiple co-morbidities necessitating careful consideration to anesthetic choices.

As noted by the ASA, trauma anesthesia allows for a unique experience in caring for patients in multiple phases of care. One aim of the rotation will be to gain experience in assessing and treating patients from early resuscitative efforts through post-operative pain management. Given the unpredictability of trauma, it is a dynamic rotation that helps foster the ability of an anesthesiologist to think quickly and remain flexible, all the while serving as an integral member of a multidisciplinary team. The skills learned during this rotation will be of great benefit on call, night float and while rotating at other hospitals.

Residents should report to the Main OR on clinical days early, acknowledging there will be many times when you are “unscheduled” the night before. There will generally be an “Ortho-Trauma” room designated, and residents on the rotation should set up each morning for a GA anticipating being assigned a case when the MSD scheduler arrives. The attending staff understands that you may not have had the benefit of “looking up” the patients the night before and will work with you in the AM to help develop an anesthetic plan for the cases that are assigned. As mentioned above, the ability of anesthesiologist to efficiently gather and synthesize data while remaining flexible in an ever-changing environment is paramount to our profession, embracing these skills during the rotation will serve you well throughout your residency and career.

Residents should log all cases/procedures in ACGME case log (involvement in 20 trauma cases are needed for completion of residency), and should spend additional time outside clinical work for independent reading. Several journal articles and book chapters will be provided and should serve as a framework for both general knowledge and basis for discussion with your attending. Feedback will be provided at multiple points throughout the rotation including verbal feedback and a final written evaluation in MedHub based on ACGME Core Competencies and Milestone based accomplishments.

Please Refer to the (LINK) – ACGME Milestones

By the end of the rotation residents should be able to:

Trauma

1. Outline the Epidemiology and Mechanisms of Traumatic Injury (MK): Blunt, Penetrating, Thermal, Chemical, Accidental and Non-Accidental

2. Identify Pre-hospital Care and Transportation of the Trauma Patient (MK, ICS, PC, P)

3. Communicate with Surgery, Radiology, Nursing Team to expedite and facilitate care

4. Define Initial Trauma Evaluation and Management Including Triage and Surgical Prioritization (MK, PC, SBP)

   • Primary and Secondary Surveys

   • Glasgow Coma Scale

   • Injury Severity Scores

5. Establish Airway Management and Vascular Access of the Trauma patient (MK, PC)

   • Difficult Airway Algorithm

     • 1. Care of patient with cervical spinal cord injury

       2. Use of bougie, video laryngoscopy, supraglottic airway devices, awake and asleep fiberoptic intubation

6. Determining appropriate venous access, invasive monitoring and need for infusion/warming devices

   • Large bore peripheral IV

   • Arterial line placement (radial, femoral) with and without use of ultrasound

   • Central venous access (IJ, Subclavian, Femoral)

7. Demonstrate Resuscitation and Stabilization of the Trauma Patient (MK, PC,SBP)

   • Guide Points of Early and Late Resuscitation

   • Blood Component Therapy and Trauma Coagulopathy

   • Massive Transfusion Protocols

8. Identify Anesthetic Consideration for Trauma and Formulate Intra-operative Anesthetic Management Plan (MK, PC, P, SBP, ICS)

9. Thoroughly and efficiently evaluate patient pre-operatively gathering data from all available resources

10. Effectively communicate plan to attending anesthesiologist and communicate with nursing/ancillary staff for concerns/special needs

11. Develop communications skills to effectively communicate with patient’s and families during time of stress to gather information and discuss risk, benefits and necessity of anesthesia

12. Identify and establish proper positioning of patient to reduce additional injury

13. Obtain and Interpret laboratory data and assimilate that information with clinical data to help guide clinical care

14. Ensure normothermia of patient

15. Maintain hemodynamic stability through the use of vasopressor agents and blood produce administration

16. Special considerations for trauma patient

    • Intoxication

    • Anti-coagulation therapy

    • Full-stomach

    • Pregnancy and trauma

17. Evaluate Post-Operative Needs and Facilitate Transitions of Care (P, SBP, PC, ICS)

    • Goals for Extubation, communication with ICU

    • Post operative pain requirements

    • Maintenance of accurate anesthetic record for transitions of care

    • Provide effective and thorough sign out to nursing/md staff in PACU/ICU

Ortho-Trauma

1. Identify common orthopedic-trauma fractures and procedures (MK): IM nail, percutaneous pinning, ORIF upper/lower extremity

2. Understanding importance of timing of procedures (urgent/emergent), to best facilitate patient care and outcomes (MK, SBP, PC)

3. Effectively communicate with Ortho-Trauma team to identify patient specific and surgeon specific needs (MK, ICS, PC, SBP)

   • Patient positioning and table selection

   • Patient comorbidities and need to intra-operative monitoring and appropriate post-operative disposition

4. Communicate with Regional/Pain service to integrate patient into multi-disciplinary care (SBP, MK, PC, ICS)

   • Hip protocol, understanding appropriates of regional blockade selection

5. Develop skills in preparing for scheduled cases as well as adapting to frequent changes in schedule and planned procedures (SBP, ICS, MK, PC, P)

   • Efficiently obtain data and evaluate patient to formulate safe anesthetic plan

   • Effectively communicate plan with attending anesthesiology, surgeon and operative staff

   • Effectively communicate with patient’s and families anesthetic plan including risks and alternatives

Geriatric Anesthesia

1. Identify and evaluate common co-morbidities associated with the elderly (MK, PC): HTN, valvular deart dx, CAD, COPD, PVD, dementia, DM, difficult IV access, anti-coagulation

2. Demonstrate understanding of changes in physiology, pharmacokinetics and pharmacodynamics in elderly (MK, PC): Circulation and distribution time, dose adjustment based on age, dose adjustment based on physiology, opioid requirement and dosing, NBMD requirement and dosing

3. Consider alternatives to procedures and standard anesthestics based on patient co-morbidities (SBP, MK, PC, ICS)

   • Neuraxial vs regional vs MAC vs GA

   • Percutaneous pinning vs IM nail vs ORIF

4. Effectively Utilize all resources to obtain pertinent patient information (SBP, PC, ICS, P): Family members, chart review, outside records, consultant services

Instructional Activities

• Syllabus with attached primary literature, book chapters, review chapters and ASA documents

• Intra-operative teaching and modeling by attending anesthesiologist and surgeon

• Daily Libero lectures, weekly resident lecture series, weekly Grand Rounds

• Perform a post-operative visit and assessment to facilitate discussion with attending anesthesiologist

• Review Hospital Protocols pertinent to rotation (Massive transfusion protocol, Hip Fracture protocol)

• Prepare an outline/summary of the provided materials to be placed in your portfolio and for your future review in preparation of ITE/AKT/Boards

• Develop Two “Boards Style Questions” from the provided material with detailed explanations to create/cultivate database for future learning of colleagues

Evaluation

Daily verbal feedback will be provided by the attending anesthesiologist”. A summative milestone based evaluation will be created at the end of the rotation based on the ACGME core competencies with input from course director and all staff who worked with resident over the course of the rotation.