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Otorhinolaryngology: Year 1

As of July 1, 2005 , all Otolaryngology Residency Programs have absorbed the PGY1 year thus making the program a 5 year program. The surgical rotations for the PGY1 year are controlled by the otolaryngology program director, and are in compliance with the residency review committee of the ACGME. The PGY1 residents have been assigned to a specific site (MMC, LIJ) for the year.

Beginning 7/1/2006 the residents were rotated to the different sites so that they will all receive an equal experience, as well as allowing us to take advantage of the best rotations at each site.

GOALS AND OBJECTIVES GENERAL SURGERY ROTATION

These areas of knowledge and skills are pertinent to the formation of residents beginning their Otolaryngology residency have been selected and supplemented as deemed appropriate by the Residency Review Committee.

Patient Evaluation, Assessment and Management
By the completion of PGY1, the resident should be knowledgeable in the following areas and be able to do:

History and Physical Examination, Documentation

  • Obtain a detailed surgical history and obtain and review relevant medical records and reports
  • Perform a detailed physical examination.
  • Develop a complete differential diagnosis.
  • Maintain a personal patient log.
  • Write a succinct H&P, including a risk assessment evaluation.
  • Obtain a written informed consent.
  • Document the treatment plan in the medical record, including the indications for treatment.
  • Dictate an operative note and discharge summary.

Patient Assessment and Perioperative Management

  • Order and interpret basic laboratory tests and screening X-Rays, and evaluate the patient's cardiac, pulmonary, renal, and neurological status.
  • Develop a preoperative assessment of risk factors.
  • Review, prioritize, and order medications the patient is currently taking, as appropriate.
  • Use and understand the nursing notes and patient data.
  • Prescribe activity level, management of medications, pain management, follow up appointments, and obtain urgent contact information.

Assessment of Basic Diagnostic Tests and X-Rays

  • Recognize abnormalities in basic radiologic and laboratory tests and learn normal values and ranges.
  • Choose the optimal imaging technique.
  • Recognize:
    • pleural effusion on CXR
    • chest mass on CXR
    • pneumonitis on CXR
    • bowel gas patterns on flat plate abdomen
    • diaphragm abnormalities on CXR
    • spinal column fractures
    • cervical spine radiographs
  • Interpret basic EKG findings
  • Recognize ischemia & arrhythmia patterns on EKG.

Management of Fluid/Electrolyte and Acid Base Balance

  • Understand acid-base balance and the applications of body composition to fluid, electrolyte, and acid-base balance in health and disease.
  • Give fluid resuscitation, manage postoperative fluid requirements, and recognize and correctly manage acid-base disorders.
  • Make adjustments in fluid administration for comorbid conditions, e.g. renal or cardiac insufficiency, diabetes, hypovolemia.
  • Use CVP and urine flow rates for adjustments of fluid administration.
  • Perform a saphenous cutdown.
  • Recognize and treat calcium and magnesium imbalance.

Fever, Microbiology, and Surgical Infection

  • Know the mediators of fever, differential diagnosis, evaluation and management of the febrile patient in order to initiate appropriate workup of fever and provide supportive treatment.
  • Initiate definitive treatment with appropriate antibiotics.
  • Be able to monitor antibiotic levels and recognize drug-related complications. Know the antibiotic of choice.
  • Know and apply the principles of prevention of nosocomial infections, sterile technique and universal precautions.
  • Order and interpret the appropriate imaging studies for localization of an infected focus.
  • Know and apply the principles of incision and drainage.
  • Know the proper use of prophylactic antibiotics.
  • Know the classification of wounds (clean, clean-contaminated, contaminated, infected).
  • Recognize the septic syndrome and initiate appropriate supportive treatment. Be familiar with the current literature concerning the causes and mediators of the sepsis syndrome and its pathophysiology.

Epidemiology and Public Health

  • Be knowledgeable in AIDS diagnosis and prevention of HIV infection.
  • Understand the epidemiology and treatment of sexually transmitted diseases and other communicable diseases.

Nutrition

  • Perform a metabolic assessment of the surgical patient.
  • Understand the metabolic implications of trauma and operation.
  • Know the indications for nutritional support of the surgical patient.
  • Know the methods of calculation of nutritional requirements in health and disease using the Harris-Benedict or similar formulae.
  • Know the composition of various enteral and parenteral formulas and adjust appropriately.
  • Calculate and order basic enteral or parenteral formulas.
  • Recognize complications of enteral and parenteral feedings.
  • Manage central IV lines.
  • Manage gastrostomy or jejunostomy feeding tubes.
  • Assess when a postoperative patient can be fed and assess adequacy of intake.
  • Know and utilize comparative costs of nutritional support methods.

Perioperative Preparation

  • Complete, document, and assess appropriate workup, write preoperative orders, and obtain required consultation from other specialists.

Surgical Skills

  • Learn surgical site positioning, preparation and draping.
  • Perform as first assistant. Know how to obtain hemostasis of small vessels and exposure of the operative field.
  • Be familiar with common surgical instruments (scalpel, forceps, scissors, needle holders, hemostats, retractors, electrocautery) and suture materials and their proper uses.
  • Perform basic maneuvers, e.g. suture of skin, soft tissues, fascia; tie knots; obtain simple hemostasis.
  • Learn basic techniques of dissection and handling of tissues.
  • Under supervision:
    • excise benign lesions of skin and subcutaneous tissues.
    • perform lymph node biopsy.
    • remove superficial foreign bodies.
    • incise and drain an abscess.
    • repair simple lacerations.
    • repair umbilical and type I and II inguinal hernias.
    • perform appendectomy.

Sterile Technique

  • Understand indications for and utilize appropriate methods of routine and reverse isolation procedures.
  • Maintain appropriate sterile technique in the ER, at the bedside, in the ICU, and in the office.

Wound Management

  • Differentiate between wound infection, hematoma, and seroma, and initiate therapy.
  • Perform extensive debridement with supervision.
  • Debride and pack wounds and apply dressings.
  • Recognize and differentiate between wound infection and necrotizing fasciitis, and detect crepitus.
  • Identify wound dehiscence and evisceration.
  • Know and apply the specific recommendations for tetanus immunization (active and passive).
  • Know the clinical manifestations of rabies in carrier and patient, and agents available to prevent development of the disease.
  • Obtain proper wound specimen and perform and interpret Gram stain.

Prioritize and Manage Complications

Assess and manage complications or change in health status, such as:

  • altered mental status
  • fever
  • hypotension.
  • hypovolemia, oliguria
  • hypoxia
  • pain
  • vomiting, distention, nausea
  • bleeding at the bedside & coagulopathy
  • atelectasis, pneumonia, aspiration
  • fecal impaction, constipation
  • chest pain
  • dyspnea
  • pneumothorax
  • congestive heart failure, pulmonary edema
  • superficial phlebitis
  • pulmonary embolus
  • urinary retention
  • diabetic ketoacidosis or hyperosmolar coma
  • peripheral ischemia or cyanosis
  • seizures, alcohol or drug withdrawal

ANESTHESIA ROTATION

The main goal of this rotation is to provide the PGY1 resident an organized experience to enable him/her to acquire the basic knowledge and skills in preoperative care including preanesthetic evaluation, anesthetic risk assessment, airway evaluation and immediate postoperative care.

At the completion of this rotation the PGY1 resident should be knowledgeable in the following areas and be able to do:

  • Basic laryngeal anatomy and physiology.
  • Appropriate indications for general vs local anesthesia.
  • Appropriate preoperative evaluation including when to order a pre-operative chest x-ray, EKG, and laboratory tests based on the patient's age, past medical history and social habits.
  • Write pre-anesthetic orders.
  • Obtain oropharyngeal control of airway and provide Ambu ventilation.
  • Be able to perform:
    • orotracheal intubation
    • nasotracheal intubation
    • laryngeal mask ventilation
    • jet ventilation
  • Interpret the anesthesia record.
  • Position the patient properly for operative exposure, temperature control, and protection frompressure/traction.
  • Be familiar with intraoperative monitoring.
  • Insert arterial and venous lines.
  • Know the dose range and complications (including pulmonary edema and malignant hyperthermia) of the following agents:
    • barbiturates
    • local anesthetics
    • paralyzing agents
    • reversing agents
    • inhalant anesthetics
  • Know when and how to use epinephrine, hyaluronidase, in local anesthesia.
  • Under supervision:
    • administer a local block
    • administer general anesthesia
    • Understand and use conscious sedation
  • ACLS certification

THORACIC SURGERY ROTATION

The main goal of this rotation is to provide the PGY1 resident an organized experience to enable him/her to acquire the basic knowledge and skills in the evaluation and management of patients with common cardiac and pulmonary surgical problems.

At the completion of this rotation the PGY1 resident should be knowledgeable in the following areas and be able to do:

  • Review applied cardiac physiology and applied pulmonary physiology
  • Critical care and management of shock
  • Basic surgical skills.
  • Evaluation and management of chest masses
  • Care for at least 15 ICU patients/month

CRITICAL CARE ROTATION (ICU)

The main goal of this rotation is to provide the PGY1 resident an organized experience to enable him/her to acquire the basic knowledge and skills in the evaluation and management of patients in the intensive care setting.

At the completion of this rotation the PGY1 resident should be knowledgeable in the following areas and be able to do:

Critical Care and Management of Shock

  • Differentiate types of shock (hemorrhagic, cardiogenic, septic, neurologic) and initiate appropriate therapy.
  • Insert central venous and arterial catheters and obtain hemodynamic data; interpret data andinitiate therapy.
  • Recognize clinic presentation of a pneumothorax and insert chest tube
  • Understand and utilize basic principles of mechanical ventilation.
  • Recognize the indications for blood component therapy and initiate therapy.
  • Recognize a transfusion reaction and initiate management.
  • Institute measures to prevent upper GI bleeding in critically ill patients.
  • Coagulation and Anticoagulation
  • Choose the appropriate tests for diagnosis of a coagulopathy, and have a working knowledge of factor analysis.
  • Apply effective preventive measures for DVT and PE.
  • Initiate and monitor therapeutic anticoagulation and its complications.
  • Diagnose and manage acute deep venous thrombosis.
  • Acutely manage a patient with a suspected acute pulmonary embolus, and provide a differential diagnosis.

Applied Cardiac Physiology

  • Recognize rhythm disturbances, myocardial ischemia on EKG.
  • Assess, formulate a differential diagnosis and initiate therapy for hypotension.
  • Know and apply appropriate treatment for supraventricular tachycardia.
  • Treat congestive failure and acute pulmonary edema.
  • Manage hypertension in a surgical patient.
  • Understand multidrug therapy and the toxic and side effects of antihypertensive drugs.

Applied Renal Physiology

  • Know the pathophysiology of the development of acute renal failure; the differentiation of prerenal, renal, obstructive types of renal failure; and the general concepts of prevention and treatment of ARF.
  • Recognize and treat simple electrolyte disturbances.
  • Understand appropriate fluid replacement and balance.

Applied Pulmonary Physiology

  • Know the manifestations-clinical and by laboratory testing-of obstructive pulmonary disease nd pulmonary insufficiency, and their surgical perioperative management.
  • Recognize bronchoconstrictive disorders and their perioperative management.

Applied Nutrition

  • Learn to manage the nutrional needs of a critically ill patient.
  • Placement of nasogastric tube and dophoff tube.

Surgical Skills

  • Develop surgical skills in CPR, CVC placement, arterial catheter placement, and chest tubeplacement.
  • Perform first assistant in bedside bronchoscopy, pulmonary lavage, and tracheotomy.
  • Obtain oropharyngeal control of airway, provide Ambu ventilation and perform orotracheal intubation.

EMERGENCY MEDICINE ROTATION

The main goal of this rotation is to provide the PGY1 resident an organized experience to enable him/her to acquire the basic knowledge and skills in the evaluation and management of patients presenting to the emergency room with emphasis on patients presenting with head and neck complaints. The PGY1 resident should also gain a better appreciation of medical conditions often seen as co-morbidities in head and neck patients including, diabetes mellitus, hypertension, stroke, congestive heart disease, respiratory distress and myocardial infarction.

At the completion of this rotation the PGY1 resident should be knowledgeable in the following areas and be able to do:

  • Conduct primary assessment and take appropriate steps to stabilize and treat patients with trauma (penetrating and blunt), respiratory distress, congestive heart failure, metabolic imbalances, myocardial infarction, and chronic pain.
  • Establish the acuity level of patients in the ER, establish priorities and define the tasks necessary to manage the patients successfully.
  • Monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their work-ups including fundamental lab tests and radiological studies.
  • Recognize and initiate treatment for an acute anaphylactic reaction.
  • Collaborate with physicians and other professionals to evaluate and treat patients, arrange appropriate placement and transfer if necessary, formulate a follow-up plan, and communicate effectively with patients, family, and involved health care members.
  • Closure of simple and complex lacerations.
  • Develop some familiarity with disaster management.

NEUROSURGERY ROTATION

The main goal of this rotation is to provide the PGY1 resident an organized experience to enable him/her to acquire the basic knowledge and skills in the evaluation and management of patients presenting with neurosurgical complaints. The resident should gain an appreciation for the collaborative efforts between the ORL and NES speciallities.

At the completion of this rotation the PGY1 resident should be knowledgeable in the following areas and be able to do:

  • Review basic cranial anatomy including cranial nerve origin and function.
  • Perform neurosurgical patient evaluation, assessment and management.
  • Learn evaluation and treatment of neurological trauma, critical care and emergencies.
  • The indications for and basic interpretation of diagnostic tests and X-rays including basic head CT and MRI imaging studies.
  • Basic neurosurgical skills, technique, and wound management including simple craniotomy, dural suturing and craniotomy closure.
  • Recognition, diagnosis, and basic management of CSF leaks.
  • Insertion and management of a lumbar drain.
  • Management of common neurosurgical complications.
  • Differentiate between stroke, TIA, and non-cerebrovascular events causing neurological symptoms and know the diagnostic techniques.
  • Participate in at least 5 major procedures (cranial decompression, craniotomy, removal of pituitary adenoma).
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