Cardiothoracic Surgery Traditional Residency

• Provide learning experiences based on measurable objectives for education of cardiothoracic surgeons during the traditional residency
• Integrate principles of basic sciences with clinical experiences
• Promote a broad understanding of the role of surgery and its interaction with other medical disciplines such as general medicine, cardiology and pediatrics
• Provide progressive responsibility from initial patient care to complete patient management
• Foster effective interdisciplinary collaborative relationships
• Provide CT residents with the ability to function as teachers and consultants
• Foster continuing education to promote lifelong individual initiative and creative scholarship
• Prepare CT residents to use research technology and skills in conducting studies that assist in solving surgical problems
• Develop professional leadership and management skills
• Promote understanding of the economic, legal and social challenges of contemporary and future surgery

At the completion of the program, the CT resident will be expected to demonstrate competence in:

• Evaluation of surgical patients including appropriate and cost-effective use of diagnostic examination
• Definition and documentation of an optimal therapeutic plan and implementation of appropriate therapy
• Knowledge of current surgical literature and progress, and appropriate application to patient care
• Facility in written and oral communication in case presentations, medical records, orders and manuscripts
• Up-to-date completion of all duties related to medical records
• A humane and considerate approach to patients and family members
• Establishment of good interpersonal relationships with medical and paramedical professionals

Since July, 2001, the ACGME requires that all surgical specialties include instruction and assessment of CT residents in six “ACGME Competencies.” CT residents must demonstrate and be evaluated on the following competencies:

• Patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health
• Medical knowledge about established and evolving biomedical, clinical and cognitive (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
• Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence and improvements in patient care
• Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families and other health professionals
• Professionalism as manifested through a commitment to carry out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population
• Systems-based practice as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

All programs reviewed by the RRC will have to demonstrate that they are teaching the six competencies and that they are also assessing resident achievement of these competencies.

1. Perform preoperative evaluation, history and physical examination of cardiac surgery patients

2. Obtain and interpret indicated diagnostic studies

3. Discuss diagnostic and therapeutic approaches to specific acquired and adult congenital cardiac diseases with the attending physicians

4. Perform and assist with selected cardiac cases, such as:

• Pacemaker and defibrillator insertions
• Saphenous vein harvest and wound closure for coronary bypass operations
• Valve and coronary operations
• Pericardial drainage operations
• Tracheostomy
• Minor vascular repairs
• Cardiectomy for donor heart procurement

5. Provide postoperative cardiac surgery follow-up care for the following cases:

• Coronary surgery
• Valve surgery
• Thoracic aortic surgery
• Pacemaker and defibrillator placement
• Congestive heart failure surgery

6. Perform percutaneous insertion of chest tubes and intravenous, intra-arterial and pulmonary artery catheters with supervision

1. Serve as first assistant or surgeon on selected major cardiothoracic cases, including:

• Coronary artery bypass surgery, minimally invasive off-pump and direct coronary artery bypass
• Valvular replacements and repairs, including minimally invasive procedures
• Thoracic aortic surgery
• Adult congenital cardiac surgery
• Complex defibrillators
• Emergency thoracotomies
• Congestive heart failure surgery, including surgical ventricular restoration, myoblast transplant and heart transplantation

2. Perform cardiac procedures under supervision, including:

• Insert intra-aortic balloon pump
• Pacemaker implantation
• Median sternotomy incision
• Aortic cannulation for cardiopulmonary bypass
• Saphenous vein and internal thoracic artery harvest
• Perform proximal and distal coronary anastomoses
• Repair of vascular trauma
• Graft replacement of aorta

3. Coordinate the work-up of emergency cardiac surgery cases with:

• Emergency room or trauma team
• Cardiac catheterization laboratory
• Diagnostic imaging services
• Laboratory (including blood bank)
• Anesthesia
• Operating room
• Perfusion services

4. Perform and assist, under supervision, with emergency cardiac surgery including trauma cases

5. Recognize and prescribe treatment for complications of cardiac surgery such as:

• Gastrointestinal bleeding
• Cerebrovascular accident
• Endocrine abnormalities
• Pulmonary complications
• Renal dysfunction
• Coagulopathy
• Dysrhythmias
• Low cardiac output status

1. Evaluation, diagnostic planning and assessment for operative approach of the patient with pulmonary, esophageal or mediastinal pathology

2. Develop necessary endoscopic skills, including flexible and rigid endoscopy for diagnostic esophagoscopy and bronchoscopy

3. Manage routine postoperative management of the thoracotomy, pulmonary resection and esophageal resection patient

4. Perform thoracotomy from multiple approaches and with different techniques

5. Perform minor procedures such as:

• Lung biopsy
• Wedge resection
• Pleural biopsy
• Decortications
• Pleurodesis
• Thymectomy

1. Demonstrate proficiency in:

• Fiber optic endoscopy
• Rigid endoscopy
• Mediastinoscopy
• Endoscopic intervention with photodynamic therapy and stent placement

2. Demonstrate expertise with thoracoscopy and approaches to the mediastinum and pleural spaces

3. Manage lung volume reduction and lung transplant patients

4. Conduct a full range of major thoracic procedures including:

• Lobectomy
• Pneumonectomy
• Sleeve resection
• Tracheal resection
• Pulmonary resection
• Esophageal resection
• Mediastinal resection
• Lung volume reduction
• Lung transplantation

5. Conduct surgeries for esophageal reflux and achalasia. Most of these procedures are minimally invasive surgeries. Some procedures are conducted as a collaborative effort between the Division of Cardiothoracic Surgery and the Division of General Surgery. The collaborative procedures include surgery for reflux disease requiring thoracotomy, paraesophageal hernia and achalasia.

1. Discuss the following conditions, then choose and justify the appropriate diagnostic and therapeutic modalities:

• Pectus excavatum
• Congenital lobar emphysema
• Esophageal or bronchial duplication cyst
• Post pneumonic emphysema

2. Identify indications for the following therapeutic modalities, and then justify/critique their use:

• Extracorporeal membrane oxygenation
• High frequency jet ventilation

3. Discuss postoperative management including the monitoring, prevention and therapeutic intervention of:

• Low cardiac output
  • Hypovolemia
  • Myocardial depression
  • Common postoperative arrhythmias
•  Postoperative bleeding
•  Postoperative hypertension

4. Manage general thoracic perioperative procedures

5. Use, set and regulate mechanical ventilators

6. Observe and:

• Insert chest tubes and pig tail catheters
• Perform thoracentesis
• Insert central venous access lines

7. Perform selected cardiac and general surgery cases, such as:

• Pacemaker and defibrillator insertions
• Straightforward cardiac repairs
  • Atrial septal defect
  • Ventricular septal defect
  • Coarctation of aorta
  • Patent ductus arteriosus
  • Minor vascular repairs

1. Discuss the pathophysiology and surgical management of congenital cardiac disease, including:

• Coarctation of the aorta
• Patent ductus arteriosus
• Atrial septal defects
• Ventricular septal defects
• Complex cyanotic cardiac disease
  
  • Transportation of great vessels
  • Tetralogy of Fallot
  • Pulmonary atresia
  • Atrioventricular septal defect
  • Total anomalous venous return
  • Hypoplastic left heart syndrome

2. Demonstrate working knowledge and use of the following:

• Temporary and permanent pacemakers
• Dialysis and ultrafiltration
• Cardiopulmonary bypass and extracorporeal membrane oxygenation

3. Perform and/or supervise pacemaker/defibrillator selection and placement

4. Serve as first assistant and surgeon on selected major cardiothoracic cases, including:

• Valvular replacements and repairs, including minimally invasive procedures
• All types of congenital cardiac surgery

5. Perform cardiac procedures under supervision, including the following:

• Median sternotomy incision
• Aortic cannulation for cardiopulmonary bypass
• Patent ductus arteriosus

Surgical conference

The CT surgery resident runs the surgical conference. In the surgical conference:

1. All cases performed in the prior seven days are reviewed for surgical correlation and management issues
2. All cases scheduled for surgery in the next seven days are presented

The CT surgery resident presents the history and physical findings as well as the EKG and ECHO findings. The latter are done in conjunction with the cardiology resident The CT surgery resident presents the catheterization physiologic data and the cardiology resident presents the cineangiography. Thus the CT surgery resident always has intimate prior knowledge of every case operated with the possible exception of emergencies, almost all of which will have been presented as add-ons at one or the other conference. Since the resident is present in virtually every procedure, this gives excellent continuity of experience from first presentation through the surgical procedure.

The monthly Heart Center Mortality and Morbidity Conference at Nationwide Children’s Hospital is a multidisciplinary quality assurance conference that includes extensive pathology input and compliments the monthly Mortality and Morbidity Conference held at Ohio State in the Division of Cardiothoracic Surgery.

Experience in the operating room

In the operating room, graded responsibility is afforded to the resident based on his or her level of training and ability. Because more than 25 percent of our patients are under 30 days of age and greater than 50 percent are less than one year of age, actual operative experience as the primary surgeon is limited compared to the adult rotation. Also, the Heart Center at Nationwide Children’s Hospital has a comprehensive interventional catherization laboratory where many of the simpler congenital heart lesions are managed with nonoperative stents or devices, e.g. atrial septal defect device closure. However, there remains enough other operative volume to meet the requirements as outlined by the ABTS. The resident is the first assistant on nearly all other cases. From this vantage point, attention is paid to his or her exposure to the anatomy, physiology and conduct of the operation for all forms of complex congenital heart disease. Special attention is paid to common anatomic variations, which might confront an adult cardiac surgeon with instruction in the necessary cannulation options and perfusion strategies.

Experience in the intensive care unit

In the intensive care unit, the patient is managed by a team that includes surgery attendings and residents, intensive care cardiologists and pediatric intensive care specialists. The CT surgery resident is expected to be at the bedside of any unstable patient, along with the attending physicians. Discussion is frequently vigorous, and in any given rotation there will be considerable exposure to almost every normal and abnormal form of cardiovascular physiology and pathophysiology. The resident presents a summary of the post-operative course of all patients each week at the surgical conference.