Duties and Training Requirements
The Medical College of Wisconsin Anesthesiology Residency is fully accredited by the Accreditation Council for Graduate Medical Education (ACGME). Graduates of the program will be ABA board eligible in Anesthesiology in accordance with ACGME requirements. Anesthesiology residents will engage in the practice of medicine dealing with but not limited to the following:
- The assessment of, consultation for, and preparation of patients for anesthesia
- Relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic procedures via knowledge and skills with regional anesthesia and pharmacologic agents.
- Simple and complex monitoring and maintenance of normal physiology during the perioperative period
- Management of critically ill patients
- Diagnosis and treatment of acute, chronic, and cancer-related pain; clinical management and teaching of cardiac and pulmonary resuscitation
- Evaluation of respiratory function and application of respiratory therapy
- Conducting clinical and basic science research
- Supervision, teaching, and evaluation of performance of personnel, both medical and paramedical, involved in perioperative care.
Milestone assessments occur monthly and are reviewed by the MCW clinical competence committee and summarized for the trainee in written format. The summary is shared with the resident and mentor and becomes a permanent part of the resident training file. These reports are used to complete required 6 month evaluations with the ABA as described in FAQs.
- Work an average of 58 duty hours per week (includes the regular workday and overnight call shifts)
- Manage a caseload of patients of all ages in a variety of settings/locations (Children’s Hospital of Wisconsin, Froedtert Hospital, St. Joseph’s Hospital, VA Medical Center), including clinics, e.g. Pre-Op and Pain and inpatient and outpatient care including in care in the field of Obstetric anesthesiology, ICU, PACU, Regional anesthesia, Pediatric anesthesiology. Caseloads vary between direct patient care, pre- and post-ops, and consults
- Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
- Coordinate care and communicate with physicians and staff
- Participate in the call schedule (in house, at home) as assigned by the Program and regulated by ACGME duty hour requirements
- Maintain professional standards and meet the ACGME core competencies and show timely progression in the milestones throughout training
- Adhere to all requirements set forth by MCWAH including all licensing requirements, duty hour logging and annual TB testing
- Maintain timely, accurate, and comprehensive medical records
- Maintain timely and accurate case logs
- Attend all scheduled educational conferences and learning activities, including lectures, simulation, journal clubs, workshops, etc.
- Take mandatory annual exams and Monthly exams in the first 6 months of residency
- Participate in Quality Improvement/Quality Assurance projects as required by program
- Provide safe and effective transitions of care
- Provide meaningful evaluations of Faculty and maintain a consistent pattern of requesting evaluations from core faculty upon completion of rotations.
- Participate in a scholarly project during residency and present the project at a local, regional or national meeting site.
A resident must possess sufficient strength and manual dexterity to carry out a variety of anesthesia related tasks including (but not limited to):
- Supporting an airway
- Providing bag mask ventilation
- Holding a laryngoscope
- Patient intubation
- Placing IVs
- Placement of intra-arterial and central venous catheters
The resident must have the physical ability to apply a force of 100 Newtons (roughly 22 lbs.) in the sagittal plane using a standard size 3 Macintosh blade. This must be maintained for a period of 60 seconds and must be able to be repeated after a 30-second break. Equivalency would be a sustained bicep contraction holding a 22-lb. dumbbell in the left hand, extended in a 90-degree fashion in front of the abdomen.
The resident must be able to work, primarily on their feet, for a maximum of 24 hours at a time. They must be able to assist in the physical transportation of patients and the operation and maintenance of anesthetic equipment as required. Residents must be able to freely move (kneel, bend, lean, squat etc.) and reach to a height of 6-7 feet to carry out a variety of anesthesia related tasks.
Residents must be able to respond to codes in a timely fashion (e.g. running or walking quickly to any floor in the hospital, at times, without the aid of the elevators).
Following is a list of clinical cases and techniques and the minimum number that must be performed to meet ACGME requirements. Each resident must meet these requirements for completion of the training program.
- 40 patients undergoing vaginal delivery. There must be evidence of direct resident involvement in cases involving high-risk obstetrics; 20 patients undergoing cesarean sections.
- 100 patients less than 12 years of age undergoing surgery or other procedures requiring anesthetics. Within this patient group, 20 children must be less than three years of age, including five less than three months of age.
- 20 patients undergoing cardiac surgery. The majority of these cardiac procedures must involve the use of cardiopulmonary bypass.
- 20 patients undergoing open or endovascular procedures on major vessels, including carotid surgery, intrathoracic vascular surgery, intra-abdominal vascular surgery, or peripheral vascular surgery. Excluded from this category is surgery for vascular access or repair of vascular access.
- 20 patients undergoing non-cardiac intrathoracic surgery, including pulmonary surgery and surgery of the great vessels, esophagus, and the mediastinum and its structures.
- 20 patients undergoing intracerebral procedures. These patients include those undergoing intracerebral endovascular procedures. The majority of these 20 procedures must involve an open cranium.
- 40 patients undergoing surgical procedures, including cesarean sections, where epidural anesthetics are used as part of the anesthetic technique or epidural catheters are placed for perioperative analgesia. Use of a combined spinal/epidural technique may be counted as both a spinal and an epidural procedure.
- 20 patients undergoing procedures for complex, life-threatening injuries. Examples are trauma associated with car crashes, falls from high places, penetrating wounds, industrial and farm accidents, assaults, and burns covering more than 20% of body surface area.
- 40 patients undergoing surgical procedures, including cesarean sections, with spinal anesthetics. Use of a combined spinal/epidural technique may be counted as both a spinal and an epidural procedure.
- 40 patients undergoing surgical procedures in whom peripheral nerve blocks are used as part of the anesthetic technique or perioperative analgesic management.
- 20 new patients who are evaluated for management of acute, chronic, or cancer-related pain disorders. Residents should be familiar with the breadth of pain management, including clinical experience with interventional pain procedures.
- Patients with acute postoperative pain. There must be documented involvement in the management of acute postoperative pain, including patient-controlled intravenous techniques, neuraxial blocks, and other pain-control modalities.
- Patients scheduled for evaluation prior to elective surgical procedures. There must be documented involvement for at least four weeks in preoperative medicine.
- Patients who require specialized techniques for their perioperative care. There must be significant experience with a broad spectrum of airway management techniques (e.g., performance of fiberoptic intubation and lung isolation techniques such as double lumen endotracheal tube placement and endobronchial blockers). The resident also should have significant experience with central vein and pulmonary artery catheter placement and the use of transesophageal echocardiography and evoked potentials. The resident must either personally participate in cases in which EEG or processed EEG monitoring is actively used as part of the procedure or have adequate didactic instruction to ensure familiarity with EEG use and interpretation. Bispectral index use and other similar interpolated modalities are not sufficient to satisfy this requirement.
- Care for patients immediately after anesthesia. There must be a postanesthesia care experience of 0.5 month involving direct care of patients in the postanesthesia care unit and responsibilities for management of pain, hemodynamic changes, and emergencies related to the postanesthesia care unit.
- Care for critically ill patients. Anesthesia residents must actively participate in all patient care activities and as a fully integrated member of the critical care team. During at least two of the required four months of critical care medicine, faculty anesthesiologists experienced in the practice and teaching of critical care must be actively involved in the care of critically ill patients and the educational activities of the residents.
- Anesthesia residents must maintain a comprehensive anesthesia record for each patient as an ongoing reflection of the drugs administered, the monitoring employed, the techniques used, the physiologic variations observed, the therapy provided as required, and the fluids administered. The patient’s medical record should contain evidence of preoperative and postoperative anesthesia assessment.
End of first 6 months, CA-1 Year
- Understand basics of anesthesia machine and routine monitors (pulse oximetry, capnography, circuits, oscillometric blood pressure cuffs, and electrocardiogram)
- Understand basics of neuromuscular blockade (relaxants, train-of-four monitoring, reversal)
- Understand use of routine vasoactive drugs
- Understand the indication for commonly used anesthetic drugs
- Understand major hemodynamic and respiratory effects of routine anesthetic agents and their indications
- Understand comprehensive examination and classification of the airway
- Understand key preoperative findings in history, physical, and laboratory work
- Understand application of Universal Precautions and aseptic technique
- Advanced Cardiac Life Support (ACLS) certification
- Manage ASA physical status 1 patients with minimal assistance for uncomplicated surgery, including induction, maintenance, emergence, and transport to the post anesthesia care unit
- Accurately estimate fluid (blood/colloid/crystalloid) requirements in routine cases
- Identify basic intraoperative problems (hyper-/hypotension, hypoxia, hypercapnia, arrhythmias, anuria, acidosis, laryngospasm) and formulate differential diagnoses and treatment plans
- Recognize key anatomic landmarks, indications/contraindications, and potential complications of regional blocks (spinal, epidural, interscalene, axillary, femoral, sciatic, popliteal, ankle)
Set up a case in a reasonable time–machine check, drugs, airway equipment
- Calibrate oxygen analyzer
- Check integrity of circuit
- Conduct a low-pressure circuit leak test
- Conduct a gas tank pressure check
- Conduct a wall gases pressure check
- Evaluate levels of volatile agents in vaporizers
- Investigate integrity of scavenging system
- Ventilator check
- Investigate integrity of CO2 absorber
- Yankauer suction
- Preparation for positioning of patient during induction
- Selection of appropriate head donut and mask strap
- Selection of cushioning for vulnerable points of contact
- Assessing the need for additional head elevation for sniffing position
- Selecting the appropriate sized mask for patient
- Nasal cannula for mac cases
- Selection of endotracheal tube: appropriate size, integrity of cuff, single lumen vs. double lumen (L vs. R bronchial tube), +/- stylet
- Selection of laryngoscope: short handle vs. long handle, Miller vs. Macintosh, appropriate size, assess integrity of light source
- Selection of LMA
- Appropriate size
- Integrity of cuff
- Disposable vs. nondisposable
- Set up anesthesia cart
Ventilate lungs via mask, and tracheal intubation of patients with easy to moderately difficult airway
- Mask ventilation
- Understanding the role of pre-oxygenation
- Recognizing the difficulty in a mask ventilation and being able to correct it
- Adequate preparation for endotracheal intubation (patient’s position, pre-oxygenation, suction, intubating equipment ready)
- Ability to recognize potentially difficult airways (Mallampati classification, patient’s appearance, previous history)
- Good skills in direct laryngoscopy with MAC and Miller blades (at least 20 successful intubations)
- Ability to describe the grade of laryngoscopy
- Ability to recognize the signs of successful intubation, to diagnose the right main stem intubation
- Ability to generate a back up plan for anticipated and unexpected difficult intubation
Place peripheral intravenous, arterial, and central catheters with minimal assistance
- Describe the sites available for arterial line cannulation
- Describe all the equipment needed and the placement of an arterial line; assemble an arterial pressure line (“arterial line set-up”)
- Place a radial arterial line with 20# arrow kit (catheter with built-in wire)
- Place a radial arterial line with 20# 2-inch intravenous cannula
- Place a radial arterial line via the transfixation method and external guide-wire
- Demonstrate proper flushing of the arterial line
- Demonstrate proper withdrawal of an arterial sample
- Demonstrate zeroing the arterial line
- Describe the 5 sites available for central line cannulation
- Describe the location of the internal jugular vein and femoral vein in relationship to the artery
- Describe the a, c, v waves and x and y descents of central venous pressure monitoring
- Place an internal jugular line with the assistance of the ultra-sound
- Place an internal jugular line without the assistance of the ultra-sound
Perform ultrasound guided regional blocks on suitable patients with assistance
- Be aware of indications and contraindications for regional blocks
- Know anatomic landmarks for regional blocks
- Be able to explain the procedure to the patient, citing risks and benefits, obtaining consent
- Prepare monitors, suction, O2 airway equipment, resuscitation drugs, anticonvulsant, start IV
- Prepare local anesthetic mixture suitable for the block ,+/- epi, +/- bicarb
- Know the toxic doses for most commonly used LA
- Prepare the stimulator, needle or regional kit suitable for the block
- Anticipate and treat common complications
Keep legible and accurate pre-, intra-, and postoperative records
- Hand-written records should be legible
- Pre-op anesthesia list should be
- Complete (review of all systems is done)
- Thorough (include all vitals, labs, studies and diagnosis with dates)
- Include the problem list and the anesthetic plan
- Intraoperative anesthesia record should be accurate and detailed, and should include
- Correct drug doses and vital signs
- Description of all intraop events (not limited to intubation/extubation)
- Documentation of antibiotics
- Post-op note should be written within 48 hours
- Communicate effectively with patients
- Deliver concise, organized case presentation to staff that includes important pre-anesthetic concerns
- Formulate and describe in detail a plan for anesthetic management of ASA physical status 1-3 patients including anticipated problems and their solutions
End of CA-1 year
- Understand physiology of significant cardiovascular events (compression of vena cava by surgeons, hypovolemia, hypervolemia, pulmonary embolism, ischemia, myocardial depression)
- Understand aspects of neuroanesthesia (management of increased intracranial pressure for craniotomy), vascular anesthesia (changes with aortic cross clamp), and orthopedic anesthesia (fat emboli)
- Understand choice of regional versus general anesthesia and need for selective invasive monitoring
- Understand basics of obstetric anesthesia (physiologic changes of pregnancy, techniques for cesarean section, special precautions)
- Understand how to obtain and apply information from a pulmonary artery catheter
- Manage, under supervision, patients with difficult airways who are undergoing elective surgery
- Perform emergency airway management with reasonable skill (rapid sequence vs. awake intubation) in the operating room and the intensive care unit
- Manage ASA physical status 3 patients for uncomplicated surgery with assistance
- Initiate management of trauma cases and other emergencies in proper sequence (airway, intravenous access, monitoring)
- Manage Cesarean section by general or regional anesthesia with assistance
- Manage patients in the post anesthesia care unit with assistance (assure adequacy of airway or adjust ventilation; manage pain, hemodynamics and fluids; and determine readiness for discharge)
- Develop and implement a rational plan for tracheal intubation of patients in the intensive care unit
- Insert central and arterial catheters independently most of the time
- Insert a pulmonary artery catheter with direction
- Perform spinal and lumbar epidural anesthesia without assistance in most patients
- Perform fiber optic or awake tracheal intubation with assistance
- Cogently discuss management plan with anesthesiology staff or surgeon for ASA physical status 3 patients
- Defend choice of monitoring
- Defend choice of anesthetic technique and drugs used with discussion of options
- Recognize when to proceed, investigate further, or cancel a case
- Participate actively in teaching medical students
End of CA-2 year
- Understand physiology and anesthetic concerns associated with pediatric anesthesia
- Understand obstetric syndromes and their anesthetic implications
- Understand routine open-heart procedures, including prebypass, bypass, and separation from cardiopulmonary bypass
- In-depth understanding of the pharmacology of a variety of vasoactive and anesthetic drugs in depth
- Perform emergency airway maneuvers, including cricothyroidotomy
- Manage medical diseases in surgical patients (pulmonary, cardiovascular, hepatorenal, endocrine)
- Manage routine pediatric, vascular, thoracic, and neurosurgical cases with assistance
- Perform spinal and lumbar epidural anesthesia in patients with extremes of body habitus
- Insert peripheral intravenous catheters in pediatric patients older than 2 years
- Perform a variety of regional blocks with frequent success
- Insert a pulmonary artery catheter with minimal assistance
- Assemble and calibrate transducers without assistance
- Manage acute postoperative pain (patient-controlled analgesia, continuous infusions of epidural opioids and/or local anesthetics)
- Cogently discuss management plan with attending and surgeon for ASA physical status 4 patients
- Review literature and participate in discussions for Journal Club
- Perform reasonably on oral board-style examinations
- Lecture to faculty and residents at teaching conferences
- Actively teach medical students
End of CA-3 year
- In depth understanding of the principles of all major subspecialties (ambulatory, cardiac, critical care, endocrine, neurosurgical, obstetrics, pediatrics, acute and chronic pain, thoracic, trauma, vascular)
- Know and address important articles in recent literature
Manage independently, with staff availability:
- ASA physical status 4 patients with multisystem diseases for complex elective or emergency surgery
- Acute and chronic pain
- Recovery room care
- Perform all aforementioned anesthetic and invasive monitoring procedures independently
- Attain the qualities and attributes fundamental to performance as a consultant anesthesiologist (according to the American Board of Anesthesiology):
- Ability to organize and express thoughts clearly
- Sound judgment in decision-making and application
- Ability to apply basic science principles to clinical problems
- Adaptability to rapidly changing clinical conditions
- Supervise and mentor medical students
- Participate actively in teaching fellow residents