ROTATION INFORMATION DEPARTMENT OF ANESTHESIA RESIDENCY TRAINING PROGRAM UNIVERSITY OF MANITOBA TRANSFUSION MEDICINE INTRODUCTION The Transfusion Medicine Rotation is divided into two week periods. One of these will be an Operating Room rotation and the other will be a Lab/consults rotation. The objective of these rotations is to develop expertise in Blood Transfusions, Blood Alternatives, and Transfusion Reactions, as well as clinical skills in massive transfusion and dealing with the perioperative bleeding patient. Along with the BCT year and other Internal Medicine and Subspecialty rotations, this Transfusion Medicine rotation is designed to allow the resident to acquire the general and specialty specific medical knowledge necessary to function as a competent perioperative physician. GOALS AND OBJECTIVES The following Rotation Specific Goals and Objectives for Transfusion Medicine, provide specialty specific emphasis to particular components of the general Program Goals and Objectives. These Goals and Objectives are written in the CanMEDS format. The resident will be expected to achieve the following goals and objectives in an appropriately incremental manner, with increasing experience. Please refer also to the National Curriculum for Canadian Anesthesia Residency for more information on expected knowledge and skills. All appropriate Program Goals and Objectives also apply to this rotation. 1. Medical Expert/Clinical Decision Maker By the end of this rotation, the resident will be able to perform the following: A. Explain the normal function of the hematological system including coagulation B. Explain the pathophysiology, diagnosis and treatment of common hematology, coagulation and transfusion problems including: i. Anemia and hemoglobinopathies ii. Thrombocytopenia iii. Hereditary and acquired coagulation disorders including: iv. Platelet disorders v. Coagulation factor disorders PENDING REVISION - 2013 Page 1 C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. vi. Anticoagulation vii. Transfusion reactions viii. Massive transfusion Apply an organized method of assessment of patients with hematological disease and communicate a succinct evaluation and management plan to Attending Staff. Explain the indications for, and demonstrate interpretation of, the common diagnostic tests (PTT, INR, Platelet count and Platelet function studies, Blood group and cross match, antigen testing) Explain the methods used to collect and test blood, process and store it’s various components, and make it available at local institutions Explain the principles of red cell and blood component transfusion and list the indications and contraindications for red cell, platelet, fresh frozen plasma, and specific factor concentrate transfusions Discuss the complications, diagnosis, and management of blood and component transfusion. Describe the work done in the CBS laboratory relating to transfusion List, identify and manage the complications of massive blood transfusion. List the alternatives to blood products for patients with low hemoglobin states including autologous blood transfusion, acute isovolemic hemodilution, and current synthetic blood strategies. Discuss use of blood product filters and blood warmers, and potential problems associated with their use. Discuss the assessment, management, and optimization of surgical patients presenting with hematological disease and/or expected large volume blood. Discuss the perioperative management of patients who refuse blood products. Explain the clinical, ethical and legal issues involved in dealing with these patients. Formulate and implement an appropriate plan for patient management based on understanding of the hematological problem, coexisting problems, and patient factors such as anxiety, discomfort, culture, language, ethnicity, age, and gender Use the Level 1 fluid resuscitation equipment. Set up and operate the cell saver. Explain the indications and warnings of the antifibrinolytics, rFVIIa, and parenteral iron. Perform acute normovolemic hemodilution, phlebotomy, and transfusion of blood products and provide a rationale that takes into account indications, contraindications, alternatives, costs and complications PENDING REVISION - 2013 Page 2 2. Communicator By the end of this rotation, the resident will be able to perform the following: A. Establish a therapeutic relationship with patients emphasizing explaining, trust, empathy, and confidentiality and elicit and synthesize relevant information from the patient and/or family, and be able to assess and take into account, the impact of a patient's age, gender, ethnocultural background, social supports, and emotional influences on illness B. Obtain sufficient information from the patient, family and/or surrogate(s) to formulate a plan for management that will take into account all considerations related to the patients medical and surgical issues as well as his/her personal beliefs C. Impart information to patients, families and/or surrogate(s) with sufficient content and clarity to allow them to understand treatment decisions and give informed consent 3. Collaborator By the end of this rotation, the resident will be able to perform the following: A. Communicate a succinct assessment and management plan to Attending Staff and to other physicians requesting consultation B. Discuss appropriate information with the director of the CBS, staff at the CBS, other healthcare providers, and (physicians and surgeons), and patients to facilitate optimal transfusion management for the patient C. Effectively consult with other physicians and health care professionals and demonstrate appropriate judgment regarding the assessment of hematological disease D. Coordinate patient care with other members of the care team, especially CBS staff, or consultation requesting physicians E. Manage urgent and crisis situations such as massive transfusion, as a team member or leader 4. Manager By the end of this rotation, the resident will be able to perform the following: A. Manage time and assign priorities for: i. Efficient use of time ii. Changes in response to emergencies B. Formulate treatment plans that take into account the cost-effective use of medical resources such as transfusion therapy, drug, or alternative therapeutic choices 5. Health Advocate By the end of this rotation, the resident will be able to perform the following: A. Demonstrate knowledge and recognition of broad health and societal issues PENDING REVISION - 2013 Page 3 with impact on the care of the patient with hematological disease including: i. Risk factors and demographics which contribute to the development of, and complications of hematological disease ii. Factors that identify high-risk patients iii. Short-term and long-term programs for health maintenance post transfusion B. Demonstrate the ability to intervene on behalf of patients regarding their care and safety 6. Scholar By the end of this rotation, the resident will be able to perform the following: A. Develop, implement, and monitor a personal continuing education strategy B. Search and critically appraise current hematology literature, and apply new knowledge based on appropriate evidence C. Demonstrate effective oral presentation of case reports, journal club, or rounds with sound synthesis of pertinent information D. Formulate questions for ongoing appraisal E. Facilitate learning of patients, housestaff, students and other professionals 7. Professional Throughout this rotation, the resident shall: A. B. C. D. E. F. G. H. Deliver highest quality care with integrity, honesty, and compassion Demonstrate appropriate interpersonal and professional behavior Practice medicine ethically consistent with the obligations of a physician Be aware of the ethical and legal aspects of patient care including refusal of blood products Show recognition of personal limits through appropriate consultation (with staff supervisors, other physicians, and other health professionals) and show appropriate respect for those consulted When appropriate demonstrate including the patient in discussions of care management Recognize potential conflict in health care situations, professional relationships, and value systems, and demonstrate the ability to discuss and resolve differences of opinion. Accept constructive feedback and criticism and use it to improve his/her care of patients CLINICAL RESPONSIBILITIES Daily Responsibilities OR Component During the OR component of the transfusion medicine rotation, the resident will be expected to perform the following functions: Screen the list in PAC daily to identify patients who will be undergoing large blood loss procedures. Assess all patients in PAC who will be undergoing large blood loss procedures during the period of his/her rotation. Formulate a plan for the optimization of the perioperative transfusion risks of the patient PENDING REVISION - 2013 Page 4 Provide the Anesthetic plan and manage the intraoperative care of the above patients that go to the OR within the period of time that the resident remains on the rotation. Consult component While on the consult component of the Transfusion medicine rotation, the resident will be expected to Answer all Blood Conservation/perioperative hematology consults (with Blood Conservation Nurse/Dr. Muirhead or Dr. Maguire at HSC and Dr.Moltzan or Dr. Bell at SBGH) Spend one day in SICU or ICS setting to learn the clinical management of blood products in the high-risk patient. OTHER RESPONSIBILITIES While on the Transfusion Medicine rotation, the resident will be expected to perform the following: Complete certification in Bloody Easy 2 Prepare a 20-30 minute presentation on topics related to Transfusion Medicine Complete the required reading a. Bloody Easy 2 Callum JL b. Principles of Transfusion Medicine, Rossi, Simon, Gould Ch:11, 12, 14 LEARNING RESOURCES During this rotation, the following resources will be available to residents in addition to those available at all times through the University Department: 1) Clinical teaching- The most important learning resource during clinical rotations is the direct teaching that occurs during discussion with staff of the management of actual cases, and topics of interest. The quality of this discussion is enhanced by communication in advance to generate a teaching plan. 2) Site Library- The University library has a collection of current textbooks relevant to the pattern of practice of the site 3) Computer access- The Health Sciences Centre has computer access within the OR for resident use in accessing literature 4) Anesthesia Toolkit – This resource may be accessed electronically by the residents through the University of Manitoba Health Sciences Library. It contains a wealth of links to useful books, journals, articles useful for clinical anesthesia but also making effective presentations, teaching, providing patient resources, and understanding evidence-based medicine. Anesthesia Toolkit can be accessed at http://umanitoba.ca/faculties/medicine/anesthesia/ PENDING REVISION - 2013 Page 5 PENDING REVISION - 2013 Page 6