Rotation: Obstetrical Anesthesiology – Senior 1 Rotation Director: Michael G. Richardson, MD (m.richardson@vanderbilt.edu) Overview: The first Senior rotation month is likely the most challenging rotation developmentally. It is designed to 1. review, re‐enforce, and advance the fundamental competencies required for routine anesthesia care of women during pregnancy and delivery, which were introduced during the Junior Rotation; 2. expand more advanced knowledge, skills, and behaviors required to care for high risk, complex, and complicated patients; 3. introduce residents to the knowledge, skills, and behaviors that will be necessary to lead and coordinate an obstetric anesthesiology team of providers in providing care for the entire active and continually dynamic high‐risk obstetric service involving 4,600 deliveries per annum; 35% cesarean delivery rate; the full range of high‐risk medical/obstetric/neonatal complexity, including critical illness; linguistic & cultural diversity (limited English proficiency in >15%); a host of disciplines (OB generalists, maternal‐fetal medicine subspecialists, two private midwifery practices, midwife attending staff, neonatologists, nurses); and routine potential for up to 30 active parturients at any one time across an expansive 4th floor maternal care arena.. While the attending +/‐ fellow are fully responsible for this subspecialty expert leadership task, they will begin to teach and guide the Senior 1 resident in developing the communication, collaboration, prioritization, and management skills needed to provide care that meets all six IOM quality dimensions of care; and 4. Introduce residents to teaching and supervision skills that will allow them to begin teaching junior residents/SRNAs fundamental clinical and procedural skills Learning Objectives [*I.O.M. Quality Dimensions: Safe, Effective, Patient‐/Family‐centered, Timely, Efficient, Equitable] Objective Patient Care: Provides High Quality Patient Care #1 #2 #3 #4 Conduct own pre‐anesthetic assessments and informed consent, especially focusing on those of parturients with medical complexity, critical illness, or challenging social situations; With faculty/fellow supervision & guidance, coordinate, supervise, and review juniors’ assessments. Maintain accurate and updated L&D Board. With supervisor guidance & assistance, formulate anesthetic plans that include consideration of uncommon or high‐risk underlying conditions Collaborate with fellow and attending in supervising/guiding/teaching junior performance of neuraxial labor analgesia (epidural, CSE) in routine, non‐complex parturients. Consistently perform routine care with little need for assistance. Conduct and manage quality* neuraxial labor analgesia (epidural, CSE) in technically challenging parturients (e.g. morbid G&O‐Sr1‐201410
Evaluation Methods  Direct Observation/Feedback  Direct Observation/Feedback  CBA  Direct Observation/Feedback  Direct Observation/Feedback Page1
#5 #6 #7 #8 #9 #10 #11 #12 #13 obesity, scoliosis, spinal instrumentation, etc.), with guidance / assistance as needed. Routine, technically non‐challenging procedures should require only occasional supervisor assistance/guidance by end of rotation. Identify, troubleshoot, and manage poorly functioning neuraxial blocks with supervisor guidance/assistance. Anticipate need for intervention, based on stage of labor, or planned obstetric interventions for delivery, with guidance. Teach and supervise juniors in block assessment and management, with supervisor guidance. Conduct, manage, supervise quality*neuraxial anesthesia (spinal; CSE; extension of labor epidural anagesia) for cesarean delivery in technically challenging parturients (e.g. morbid obesity, scoliosis, spinal instrumentation, emergencies, etc.), and in medically complex patients, with supervisor guidance / assistance. Teach / supervise junior trainees in the conduct of cesarean delivery anesthesia with supervisor guidance/assistance. Conduct quality* general anesthesia care for emergency cesarean delivery, with supervisor assistance Coordinate timely and thorough completion of daily post‐partum follow‐ups; Ensure continued follow‐up and management of parturients with complications, with supervisor guidance. Demonstrate leadership as a senior OBET responder, with supervisor’s guidance/direction. Collaborate with fellow or attending in defining clinically appropriate priorities when caring for multiple OB patients, adjusting continually as conditions change. With guidance, identify and manage factors predisposing parturients to adverse outcomes (medical or obstetric risk factors; limited resources [personnel; space]; limited knowledge [need for consultants, tests]; communication barriers) With supervisor guidance and assistance, construct appropriately prioritized differential diagnoses for acute clinical deterioration; Collaborate with supervisor and L&D team to initiate appropriate intervention. Anticipate, prevent, recognize, and initiate treatment of common complications and adverse events attributed to neuraxial anesthesia.  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback Objective Medical Knowledge: Obstetric Anesthesiology #1 With assistance, demonstrate sound understanding of, by integrating & applying clinically, foundational concepts (18 core topics) – normal & complicated mat/ fetal/ placental physiol; maternal co‐morbidities; OB mgmt practices; implications for OB anesthesia management G&O‐Sr1‐201410
Evaluation Methods  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA Page2
#2 #3 #4 Demonstrate understanding, and apply clinically, basic fetal /neonatal concepts – EFM patterns & categories, routine neonatal physiol & assessment (Apgar) Demonstrate basic understanding, and with assistance, apply clinically, advanced concepts (those prompted by unique pts, situations, complications, consults, CBAs) Demonstrate understanding, and with assistance, apply legal & ethical concepts (informed consent, autonomy, patient rights, treatment refusal, vulnerable pop’ns, emancipated minor, termination of pregnancy) clinically.  Direct Observation/Feedback  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA Objective Practice‐based Learning and Improvement: Self‐directed learning and scholarly activity #1 With faculty/fellow guidance, locates, appraises, & assimilates evidence relevant to practice issues; disseminates to educate team members, in timely fashion #2 In collaboration with supervisors, systematically analyze own & team’s performance and patient outcomes, and implement changes to improve #3 Seeks openly reflect on/ discuss post‐anesthesia follow‐up (patient feedback) to assess quality & identify improvement ideas #4 Proactively seeks out feedback and advice from supervisors  uses it to improve Evaluation Methods  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  CBA Objective #1 #2 #3 #4 #5 Interpersonal and Communications Skills: Communication with patients and families With guidance from supervisor, communicates complex information to mother & support persons in respectful, responsive, effective, & culturally sensitive manner With guidance, obtains informed consent for complex procedures, or in challenging situations, using language appropriate to mother and family’s level of understanding With guidance, supervises / teaches juniors regarding interpreter services – identifying need, recruiting of services, using effectively , consistently, and independently Communicates & collaborates effectively with inter‐professional team (nurses, techs, OBs, CNMs, consultants) With guidance, organizes & leads clinical team to provide simultaneous care for multiple patients on service G&O‐Sr1‐201410
Evaluation Methods  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback Page3
#6 #7 With guidance, discerns conflict or misunderstanding (actual; potential); engages to promote resolution or improved understanding (social intelligence) With guidance, titrates support, supervision, guidance of learners – observes, debriefs, gives feedback, promotes reflection  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations Objective Professionalism #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 Demonstrates awareness of & complies with expectations & policies (rotation, dept, L&D, institution… clinical, educational, duty hours, etc.) Timely completion of documentation (StarPanel; GasChart; consents) & reading/written assignments (educational; evaluations) Actively participates in conference & discussion; mindful of “law of fractions”; respects others’ contributions Seeks to understand alternative perspectives; promotes open‐
mindedness/ non‐judgment Seeks and accepts constructive feedback. Provides constructive feedback in tactful & supportive way Conducts all work with honesty & integrity, participating fully in clinical care and educational activities. With faculty guidance, leads effectively and fairly. Seeks awareness of barriers to care; advocates for vulnerable patients With faculty guidance, leads in disclosing errors & complications in clear, honest, timely fashion With supervisor guidance, demonstrates need to balance teaching/learning with patient/clinical care needs. Responsive to pts’ needs over self‐interest Demonstrates commitment to maintaining own personal emotional, physical, and mental well‐ being; demonstrates concern that other team members do the same Evaluation Methods  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  CBA 
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Direct Observation/Feedback 360° Evaluations Direct Observation/Feedback 360° Evaluations  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations Objective Systems‐based Practice #1 #2 #3 Collaborates effectively with L&D teammates (nurses, techs, OB res/attgs, midwives, MFMs) Routine participation in L&D Mid‐Shift Briefing and Board Sign‐
out Rounds With support from supervisor, prepares thoroughly and leads morning and afternoon transitions of team care, sharing critical pt info, ensuring continuity & safety With guidance, provides care that integrates cost awareness, G&O‐Sr1‐201410
Evaluation Methods  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback Page4
#4 #5 #6 resource limitations, best practices, and quality care Actively participates, and with guidance, demonstrates anesthesia team leadership, during OB Emergency Team responses With guidance, reflects on and discusses complications, identifying potential system/communication factors, with the aim of identifying system & safety improvement opportunities. Participates with others to improve teamwork, collaboration, and communication in order to reduce system errors & enhance patient safety  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations TEACHING METHODOLOGIES Students on this rotation will be expected to learn and achieve the learning objectives through the following methodologies and activities: 
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Attendance & Active Participation in Daily Morning Conference Complete Required Daily Reading Assignments Clinical Experience providing ante‐/intra‐/post‐partum care for pregnant women Informal & Formal Feedback / Team Debrief sessions Modeling, guidance, and direct supervision by Fellow/ Attendings Participation in transitions of care o Daily morning and afternoon/evening OB Anesthesiology team hand‐over o L&D Board Rounds (evenings; weekends) and twice daily L&D Mid‐Shift Briefings  Supplemental readings that are relevant to cases or impromptu topics  Case Based Assessment PATIENT ENCOUNTERS Residents on this rotation will be expected to work up and/or manage the minimum number of patients/cases with the specified conditions as listed below: (e.g., 10 craniotomies, 20 vaginal deliveries with CLE, etc.) Number Patient Condition / Case 20 Pre‐anesthetic evaluation/informed consent – Complex Cases 8 Post‐analgesic/‐anesthetic evaluation (post‐partum) – Complicated Cases 20 Continuous Epidural Labor Analgesia – Technically challenging or High‐Risk 5 Forceps‐assisted vaginal delivery G&O‐Sr1‐201410
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15 Extension of Epidural Labor Analgesic block for Cesarean Delivery ‐ 15 Spinal / CSE Anesthesia for Cesarean Delivery ‐ 2 External cephalic version 2 Post‐partum sterilization procedures 1 General Anesthesia for Emergency Cesarean 10 Use of Language Line Interpreter Services for pre‐anesthetic evaluation/informed consent, and for performance of anesthetic care/procedures (labor analgesia; block assessment; cesarean delivery) FEEDBACK Please identify when and how the student will receive feedback on his/her performance. Daily  Verbal Final  Written  Verbal Michael G. Richardson, MD 16 October 2014 G&O‐Sr1‐201410
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