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General Objectives

On completion of this rotation, the resident will build upon previous junior rotational experience in Cardiac Surgery on the presentation, pre-operative preparation, surgical management, and post-operative care of cardiac surgical patients.Ìý This rotation will form a link between the junior rotation and the chief year.Ìý The senior resident will assume a leadership role in the management of the cardiac patients, and improve technical skills to a point of becoming a semi-independent cardiac surgeon.

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Specific Objectives

MEDICAL EXPERT

Knowledge

Knowledge of the principles essential to the care of cardiac surgical patients as outlined in the Goals and Objectives of the Junior Rotation in Cardiac Surgery.

These include:

• Thorough understanding, recognition and management of medical conditions, including diabetes, renal dysfunction, respiratory problems, cardiovascular disease as well as peripheral vascular disease.
• Knowledge and management of vascular, neurological and general surgical complications in cardiac surgical patients, including peptic ulcer disease, limb ischemia, colonic ischemia.
• Knowledge of the management of all of the major complications of cardiac surgical patients, including post-operative hemorrhage, tamponade, low output state, myocardial infarction, post-operative sepsis, respiratory dysfunction, neurological dysfunction, and vascular disease.
• Knowledge and management of wound complications, including drainage, re-wiring and flapping.
• Knowledge of the pathophysiology of cardiopulmonary bypass, including its deleterious effects and catastrophic complications of cardiopulmonary bypass.
• Knowledge of the mechanisms of myocardial injury and their prevention during cardiac surgical procedures.
• Knowledge of the different types of myocardial protection techniques, including hypothermia, cardioplegia and substrates.
• Knowledge of the anatomy of coronary circulation as seen in coronary angiography.
• Knowledge and the ability to diagnose coronary pathology.
• Knowledge and the ability to diagnose pathology using standard imaging techniques for myocardial ischemia, including electrocardiogram, stress test, coronary angiography, nuclear medicine test, and stress echocardiography.
• Knowledge and ability to manage both medically and surgically coronary insufficiency, including the indications for and contra-indications for myocardial revascularization.
• Knowledge of and the ability to manage patients with unstable angina prior to surgery.
• Ability to manage patients in acute myocardial infarction with its mechanical complications, including VSD, cardiac rupture and mitral insufficiency.
• Knowledge of and the ability to manage patients pre-operatively with valvular heart disease, including those with aortic regurgitation and stenosis, mitral regurgitation and stenosis, and tricuspid regurgitation and stenosis.
• Knowledge of the indications and contra-indications to surgical management in all types of valvular pathology.
• Knowledge of the various techniques of valve surgery, including mitral valve repair and indications for aortic root enlargement.
• Knowledge and management of the traumatic chest injury, including diagnosis and therapy for blunt and penetrating trauma to the chest, specifically aortic disruption, cardiac stab wounds, and pulmonary injury.

Technical Skills

The following is a list of specific skills the resident should acquire in the 6-month rotation:

• Be able to perform primary sternal opening and closure without difficulty.
• Be able to perform mammary harvesting of the left internal mammary artery.
• Be able to harvest saphenous vein and if needed left radial without difficulty.
• Be able to institute cardiopulmonary bypass in first time cardiac surgical patients undergoing coronary bypass surgery as well as valvular surgery.
• Ability to set up for the delivery of both antegrade and retrograde cardioplegia.
• Ability to insert antegrade cardioplegia techniques using hand-held catheters as well as indirect and direct establishment of retrograde coronary sinus catheter intubation.
• Be able to inspect the aorta for atherosclerotic disease using palpation and interpretation of transesophageal echocardiographic material.
• Be able to correlate pre-operative coronary angiography with intra-operative coronary anatomy.
• Be able to perform proximal anastomosis of reverse saphenous vein grafts onto aorta as well as distal anastomoses on appropriate large distal coronary arteries.
• Be able to wean from cardiopulmonary bypass with special attention to temperature, ECG, acid base balance, hematocrit, perfusion pressure.
• Be able to recognize need for further inotropic support and/or intra-aortic balloon pump.
• Be able to insert percutaneously intra-aortic balloon pump either through a femoral artery or femoral artery cutdown.
• Be able to time aortic balloon pump appropriately.
• Be able to recognize tamponade and open patient appropriately.
• Be able to set-up for aortic and mitral valve surgery, including appropriate incisions on the aorta and in the left atrium.
• Ability to inspect aortic and mitral valve pathology.
• Ability to obtain hemostasis following surgical procedure.
• Ability to close sternal opening safely and securely.
• Be able to first assist in all other complex cardiac surgeries, including re-do, combined valvular heart disease, and combined coronary and valvular disease.

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COMMUNICATOR

• Obtain cardiac history from patients and their relatives in the elective and emergency condition.
• Supervise junior residents in history and physical examination.
• Lead scheduled daily rounds with a combined team of nurses, residents and students.
• Write clear notes, including pre-operative indications for surgery and post-operative reports at least every other day.
• Make sure an appropriate discharge summary has been performed either by the medical student or the junior resident, and is appropriately sent to the referring cardiologist and family doctor.
• Communicate directly with attending staff members on problems with patients as well as with the ICU attending and staff.

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COLLABORATOR

• Work with multidisciplinary teams on the ward, in the operating room, and in the ICU.
• Co-ordinate and identify social concerns regarding patients and consult appropriately with allied health care professionals, including social workers, physiotherapists, occupational therapists.
• Advise attending staff appropriately and consult medical specialists and allied health care professionals when needed.
• Run and co-ordinate multidisciplinary rounds on the ward.

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MANAGER

• Attempt to use evidenced based medicine during management of patients and refer to appropriate literature.
• Record, along with data collectors, complications on the service according to the Division of Cardiac Surgery standards.Ìý These will be presented at Morbidity and Mortality Rounds.
• Prepare to run Morbidity and Mortality Rounds and present on specific topics and review literature.

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HEALTH ADVOCATE

• Involve patients and families in primary and secondary prevention of coronary artery disease.
• Counsel the patients appropriately under exercise, diet, rehabilitation, and smoking sensation.
• Ensure that the patient has appropriate follow-up with cardiologist, Wound Clinic or cardiac surgeon.
• Be sure the patient understands the risks and benefits of cardiac medications, including Coumadin.
• Make sure the patient understands the issues of prevention regarding thrombosis and bleeding in a patient with mitral valve repair or replacement.
• Be able to appropriately prescribe lipid lowering medications.

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SCHOLAR

• Develop a self directed reading and consulting strategy with other professionals.
• Contribute to Service Rounds via presentations and knowledge gained through case experiences and literature.
• Be responsible for teaching junior residents and medical students on the service as well as allied health care professionals.Ìý This would occur, when appropriate, during daily rounds and organize at least once a week ‘walk around rounds’ with members of the service.
• Do regular reading around specific cases, and when appropriate perform a literature review.
• Participate actively in all scheduled rounds.

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PROFESSIONAL

The senior resident will become an example to other members of the team and promote the following:

• Deliver the highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behavior.
• Practice medicine ethically consistent with the obligations of a physician.