otr & str - cardiac surgery (2004) eng

2 SAUDI BOARD CARDIAC SURGERY CURRICULUM

COPYRIGHTS AND AMENDMENTS

©2016 Saudi Commission for Health Specialties. All rights reserved.

This material may not be reproduced, displayed, modified, or distributed without written permission from the copyright holder. No other use is permitted without prior written permission from the Saudi Commission for Health Specialties. For permission, contact the Saudi Commission for Health Specialties, Riyadh, Kingdom of Saudi Arabia.

Any amendment to this document must be approved by the Specialty Scientific Council and the Executive Council of the Commission. Amendments shall be considered effective from the date on which the revised electronic version is published on the commission’s website, unless a different implementation date has been agreed upon.

Correspondence: Saudi Commission for Health Specialties P.O. Box: 94656 Postal Code: 11614 Contact Center: 920019393 E-mail: [email protected]

Website: www.scfhs.org.sa

Formatted and Designed by: Salem Altamimi (SCFHS)/Manoj Thomas Varghese, CMT (SCFHS)

mailto:[email protected]

http://www.scfhs.org.sa/



TABLE OF CONTENTS

SAUDI BOARD CARDIAC SURGERY CURRICULUM 3

TABLE OF CONTENTS

SAUDI BOARD ....................................................................................................................... 1

TABLE OF CONTENTS .......................................................................................................... 3

ACKNOWLEDGEMENTS ...................................................................................................... 5

INTRODUCTION .................................................................................................................... 6

CORE SURGICAL TRAINING FOR CARDIAC SURGICAL RESIDENCY PROGRAM .... 7Objectives 7

Candidate’s Enrollment Criteria 8

Admission Requirements 8

Training Requirements 8

Structure of Training 8

Research Activity 9

CARDIAC SURGERY SPECIALTY TRAINING .................................................................... 10Training Requirements 10

General Rules 10

Vacation 11

Minimum Number of Operations Required in Cardiac Surgery 11

COMPETENCIES .................................................................................................................... 13General Objectives 13

Specific Objectives 13

Medical Expert/Clinical Decision-Maker 13

Communicator 15

Collaborator 15

Manager 15

Health Advocate 16

Scholar 16

Professional 17

ROTATION BASED TRAINING OBJECTIVES ................................................................... 18General Surgery 18

Trauma Surgery 18

Thoracic Surgery 20

Vascular Surgery 22

Intensive Care Unit (ICU) 23

Cardiac Catheterization 27

Echocardiography 28

TABLE OF CONTENTS


Junior Adult Cardiac Surgery 29

Cardiopulmonary Bypass 31

Myocardial Protection 32

Ischemic Heart Disease 32

Valvular Heart Disease 32

Thoracic Aortic Pathology 33

Transplantation and Cardiac Failure 33

Electrophysiology 34

Senior Adult Cardiac Surgery 34

TEACHING AND LEARNING ................................................................................................ 37Structure 37

General Topics 37

ASSESSMENT ......................................................................................................................... 44Annual Assessment 44

Continuous Appraisal 44

End-of-Year Examination 45

Principles of Cardiac Surgery Examination (Saudi Board Examination: Part I) 45

Final In-training Evaluation Report (FITER)/Comprehensive Competency Report (CCR) 45

Final Cardiac Surgery Board Examination (Saudi Board Examination: Part II) 45

Certification 46

REFERENCES.......................................................................................................................... 47

APPENDICES .......................................................................................................................... 48

TRAINING SITES ................................................................................................................... 49Number of Candidates Accepted 49

Qualified Centers or Hospitals for Training 49

Responsibilities of the Supervising Consultants 49

Responsibilities of the Program Directors 50

Sponsorship 50

ACKNOWLEDGEMENTS


ACKNOWLEDGEMENTS

The Cardiac Surgery curriculum team appreciates the valuable contributions and feedback from all members of the supervisory committee during the construction of this manual. The team wishes to gratefully acknowledge the CanMEDS Framework, developed by the Royal College of Physicians and Surgeons of Canada. In addition, we would like to express our appreciation to all the physicians who have been instrumental in the different phases of this curriculum.

INTRODUCTION


INTRODUCTION

Saudi Arabia has a population approaching 30 million and is expanding rapidly, compared to other nations in the world. The cardiovascular risk profile is similar in a way but different in many ways from the rest of the world. For cardiovascular disease, the prevalent risk factors are hypertension in 20%, diabetes in 23.5% and coronary artery disease in 6% of the population. In addition, there is a high incidence of smoking among the young people in Saudi Arabia.

Saudi Arabia has a young population, 50% of whom are less than 25 years of age. Combined with the high-risk profile of the Saudi Arabia population, these factors culminate into a clear future crisis that may occur in the coming 15 years. As such, we have to be prepared for a cardiovascular epidemic when the young population enters their 40s and 50s.

Aside from this, rheumatic valvular disease requiring repair or replacement is quite prevalent in different parts of Saudi Arabia. From the prospective of acquired heart disease, there will also be a higher need for cardiac surgical procedures in the coming years to satisfy the increasing incidence of this disease.

The incidence of congenital heart disease is higher in Saudi Arabia than the rest of the world, accounting for 10 out of 1,000 (worldwide incidence is only 7 out of 1,000). This can be explained by consanguineous marriage, and indeed the need for congenital heart surgery will be more than the rest of the world. As it is, long waiting lists are available to take care of these patients, and as these patients get repaired, they will need adult congenital care.

Putting together all the information detailed above, cardiac surgery is clearly in demand in Saudi Arabia. This specialty is tremendously lacking in the country and this residency program is designed to satisfy this need.

CORE SURGICAL TRAINING


CORE SURGICAL TRAINING FOR CARDIAC SURGICAL RESIDENCY

PROGRAM

This is a structured program of Core Surgical Training for the Cardiac Surgery Program. It encompasses education in basic sciences, training in cognitive and technical skills, development of clinical knowledge and maturity, and acquisition of surgical judgment.

The program provides an opportunity for residents to learn in depth the fundamentals of the basic sciences as applied to clinical surgery. These include the elements of wound healing, homeostasis, hematological disorders, oncology, shock, circulatory physiology, surgical microbiology, respiratory physiology, gastrointestinal physiology, genitourinary physiology, surgical endocrinology, surgical nutrition, fluid and electrolyte balance, metabolic response to injury, principles of immunology and transplantation, applied surgical anatomy and surgical pathology.

The program provides experience in preoperative, operative and postoperative care of patients in all areas that constitute the principal components of general and subspecialty surgery related to Cardiac Surgery.

Objectives

General Objectives To prepare the cardiac surgical resident for training in subsequent years.

Specific Objectives At the end of training, the candidate should have the following capabilities and skills:

A sound knowledge of the principles of surgery.

Perform thorough and suitably oriented history taking and physical examination.

Formulate reasonable and comprehensive differential diagnoses and recognize common disorders in his specialty, as well as many of the rare ones, especially those that areamenable to treatment.

Recognize emergency situations and manage them effectively.

Select relevant investigations logically and conservatively, and interpret their resultsaccurately.

Manage common problems in general surgery and acquire knowledge of management alternatives.

Perform various surgical, diagnostic and therapeutic procedures and operations, especiallythose used in the management of emergencies and common surgical problems.

Communicate well with the patient, the relatives and colleagues.

Keep orderly and informative medical records.

Educate and update himself and others in his field.

Advice colleagues from other specialties with regard to problems related to surgery.

Possess high ethical and moral standards.



Candidate’s Enrollment Criteria

The Candidate should be a medical school graduate who has completed internship.

The Candidate should fulfill all his employment requirements and legal issues.

Each candidate must have a valid license/registration from the Saudi Council of HealthSpecialties.

The candidate should complete 36 months of core surgical training. Rotation may not be inthe same order of listing.

Admission Requirements

To be accepted in the training program, the candidate must fulfill the following requirements:

Obtain a Medical Degree (M.B.B.S.) or equivalent from a recognized university.

Successfully complete rotating internship of 12 months.

Pass the admission examination and interview.

Provide names of two consultant physicians as references, recommending the candidate assuitable for higher surgical procedures.

Provide a letter from a sponsoring organization stating that the candidate can participatein full time training for the whole period of the program (7 years).

Provide a signature of obligation to abide by the rules and regulations of the trainingprogram and the Saudi Specialty Certificate of Surgery.

Register as a trainee at the Saudi Commission for Health Specialties.

Training Requirements

Training is a fulltime commitment. Residents shall be enrolled in continuous fulltimetraining for the whole period of the designed 3-year training.

Training is to be conducted in institutions accredited by the Saudi Specialty Certificate ofSurgery.

Training shall be comprehensive and includes inpatient, ambulatory and emergency roomcare.

Trainees shall be actively involved in patient care with gradual progression ofresponsibility.

Trainees shall abide by the training regulations and obligations as set by the Saudi SpecialtyCertificate of Surgery.

Structure of Training

This is a three (3)-year graduate program of structured training in general surgery for the Cardiac Surgery Program. It includes a minimum of 12 months residency training in a general surgery unit. The remaining 24 months shall be allocated for rotations in various surgical subspecialties.

The candidates should complete 3 years (144 weeks) in the Core Surgical Specialty. Rotations may not be in the order of listing.



A minimum of 6 months mandatory rotation in general surgery in the first year and another 6 months in the third year core training are required.

Cardiac Surgery Specialty Training is a four (4)-year (192 weeks) program divided into two (2) phases: Junior Cardiac Surgery for 2 years and Senior Cardiac Surgery for 2 years. Rotations are not necessary in the same order.

Research Activity

The trainee shall be encouraged to participate in research activities during this training period under the guidance and supervision of his trainers. During the 6-week academic enrichment, a written research output should be submitted to the program director.

CORE SURGICAL TRAINING: 3 YEARS (144 WEEKS)

TIME SPECIALTY

48 Weeks (12 months) General Surgery, including minimum 3 months in Trauma Surgery

12 Weeks (3 months) Thoracic Surgery (Junior)

12 Weeks (3 months) Vascular Surgery (Junior)

12 Weeks(3 months) Pediatric Surgery

12 Weeks (3 months) Multi-Disciplinary Intensive Care Unit

8 Weeks (2 months) Adult Cardiology

4 Weeks (1 month) Echocardiography

4 Weeks (1 month) Cardiac Catheterization Laboratory

8 Weeks (2 months) Elective Rotation

24 Weeks (6 months) Academic Enrichment (a research proposal should be completed with a mentor)

The above will be done in collaboration with the General Surgery Board, in a center accredited by the Saudi Board in General Surgery, under the supervision of the cardiac surgery program director.

CARDIAC SURGERY SPECIALTY TRAINING



Training Requirements

Track 1 Promotion to senior year depends on successful completion of Core Surgical Training and passing of the Cardiac Surgery Core Examination.

Track 2 Candidates with full certification from the board of General Surgery or equivalent as recognized by the Saudi Council for Health Specialty can be considered for Cardiac Surgery Specialty training (year 4) after discussion and approval by the Scientific Committee.

General Rules

A) Responsibilities

Trainees shall be responsible for inpatient care in their unit, especially clerking and following the admitted patients, with completion of the patient’s medical records,including a complete history and physical examination, investigation requests and results,plan of management, postoperative orders and progress notes, discharge summary and other relevant reports.

The trainees shall attend specialty surgical outpatient clinics at least once weekly andparticipate in the management plans of the surgical patients under the supervision of thesenior staff member.

Trainees shall be required to attend and participate in the operative sessions conducted inthe operating rooms, outpatient or day surgery units.

Trainees shall have minimum on-call duty (24 hours duty) of one in every four nights.

Trainees shall maintain healthy relations with patients, their relatives, and medical, nursing and administrative staff.

Trainees shall maintain the confidentiality and ethics of the profession.

B) Content of Training

Academic and Clinical Activities Trainees are required to attend and participate in the academic and clinical activities of the department, such as ward rounds, journal clubs, surgical pathology, radiology and immunology, and other activities. Attendance and participation shall not be less than 75% of the number of activities within any training rotation/period. They shall attend all the weekly academic half-day sessions, which will be held in each city.



Cardiac Specialty Training: 4 Years (192 Weeks)

Junior Residency in Cardiac Surgery Period of Training

Year 4 and Year 5 Adult Cardiac Surgery 48 Weeks (12 months)

Congenital Cardiac Surgery 24 Weeks (6 months)

Thoracic Surgery (Senior) 12 Weeks (3 months)

Vascular Surgery (Senior) 12 Weeks (3 months)

Senior Residency in Cardiac Surgery Period of Training

Year 6 and Year 7 Adult Cardiac Surgery 72 Weeks (18 months)

Elective-choice of adult or congenital 24 Weeks (6 months)

Vacation

During 3-month rotations, residents can take 2-week vacations at most, depending on the decision of the Program Director, with a maximum of 4 weeks / year, excluding National Holidays.

Minimum Number of Operations Required in Cardiac Surgery

The Candidate should be considered for the Saudi Board in Cardiac Surgery only when he/she has performed at least 70% of the following numbers of cases as the first operator.



Adult Cardiac Surgery

Minor Major

Perform sternotomy, thoracotomy 50 Cases of coronary anastomoses

Perform saphenous vein harvesting 25 Cases of aortic valve replacement

Perform mammary artery harvesting 25 Cases of mitral valve replacement or repair

Perform radial artery harvesting 25 Cases of tricuspid valve replacement or repair

Perform aortic and venous cannulation

Perform pericardial window drainage

Perform electrical lead insertion

Perform insertion of intraaortic balloon pump (IABP)

Perform extracorporeal membrane oxygenation (ECMO)

Perform wound debridement and wire removal

Congenital Cardiac Surgery

Closed Procedure Open Procedure

Patent ductus arteriosus (PDA) ligation Atrial septal defect (ASD)

Pulmonary artery (PA) banding Ventricular septal defect (VSD)

Blalock-Taussig (BT) shunt Atrioventricular (AV) CANAL

Coarctation of the aorta Tetralogy of Fallot (TOF) repair

Vascular rings AVR, MVR, TVR and PVR

Diaphragmatic plication) Partial Anomalous Pulmonary Venous Drainage (PAPVD

Thymectomy Pulmonary artery (PA) reconstruction

Subaortic membrane resection

Interrupted aortic arch

Glenn, Fontan procedures

COMPETENCIES


COMPETENCIES

Definition Cardiac Surgery is that branch of surgery concerned with diseases of the pericardium, heart and great vessels. The resident who has completed training in Cardiac Surgery is expected to function as an independent consultant with respect to the diagnosis and management of patients with cardiovascular diseases, including the provision of surgical intervention when indicated and postoperative care.

General Objectives

On completion of the educational program, the graduate physician will be competent to function as a consultant in Cardiac Surgery. Residents must demonstrate the knowledge relating to gender, culture and ethnicity pertinent to cardiac surgery. In addition, all residents should demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis. Appropriate roles for the cardiac surgeon include the following: medical expert and clinical decision maker, communicator, collaborator, manager, health advocate, scholar, and research scientist. As a dedicated professional, and consistent with the obligations of a physician, the cardiac surgeon must endeavor to deliver the highest quality care with integrity, honesty and compassion, exhibit appropriate personal and interpersonal professional behavior and practice medicine ethically, giving priority to the needs of individual patients. Continuing education and evaluation are expected throughout the cardiac surgeon’s professional life, including an appreciation of the role of research and the need for critical analysis of current scientific and practice developments related to the specialty.

Specific Objectives

At the completion of training, the resident will have acquired the following competencies and will function effectively as a:

Medical Expert/Clinical Decision-Maker

General Requirements 1) Demonstrate diagnostic and therapeutic skills for ethical and effective patient care. 2) Access and apply relevant information to clinical practice. 3) Demonstrate effective consultation services with respect to patient care, education and

legal opinions.

Specific Requirements 1) Acquire knowledge of the principles essential to care of cardiac surgical patients including:

Median sternotomy and thoracic incisions and other relevant incisions for the surgicalapproach to conduit harvest and vascular access;

Wound complications and their management, including sepsis: causes, prevention,presentation, treatment;

Surgical nutrition;

Anticoagulation: indications, complications, management of heparin-inducedthrombocytopenia;

COMPETENCIES


Cardiac medications: inotropes, antiarrhythmics, vasoactive agents; use and complications;

Recognition and management of concomitant medical conditions, including diabetes, renal failure, respiratory failure, etc.;

Principles of diagnosis and management of the trauma patient, particularly thoracic orcardiac injury;

Recognition and management of vascular, neurological and general surgicalcomplications in cardiac or thoracic patients including peptic ulcer disease, hepatobiliary disease, limb ischemia, etc.;

Natural history, presentation, investigation and management of extracranial cerebral vascular disease, particularly when presenting with cardiac disease;

Anesthetic management, including the use of sedatives, analgesics and localanesthetic agents.

2) Acquire the following clinical skills:

Recommend appropriate surgical approach.

Recognize and treat wound complications, including infections, dehiscence,mediastinitis and prescribe appropriate prophylactic measures for infection prevention.

Institute and monitor surgical nutrition via enteral or parenteral route.

Recognize need for and appropriate use of cardiac, respiratory, diabetic medications.

Manage patients with concomitant medical problems, including control of diabetesand other endocrine imbalances, renal failure, and respiratory insufficiency.

Diagnose and institute appropriate management of trauma patients.

Diagnose and institute appropriate management of gastrointestinal complications incardiac patients.

Diagnose and institute appropriate management of generalized atherogenesis.

Recommend appropriate investigations and therapeutic interventions for patientswith cerebrovascular disease, particularly when presenting with concomitant cardiac disease.

3) Acquire the following technical skills:

Perform sternotomy and thoracotomy incisions: understand and perform techniquesfor safe redo sternotomy or thoracotomy.

Perform wound debridement, re-suturing of sternum or thoracotomy wound.

Insert central venous and arterial cannula for parenteral nutrition, dialysis andhemodynamic monitoring.

Insert chest tubes, resuscitate trauma patients.

Perform repair of traumatic injuries to chest including thoracic aortic tears, cardiaclacerations, and lung lacerations.

Implant appropriate devices including pacemaker and defibrillator systems, intraaorticballoon pumps and other cardiopulmonary support devices.

Manage airway problems including performance of tracheostomy.

COMPETENCIES


Communicator

General Requirements 1) Establish therapeutic relationships with patients and families. 2) Obtain and synthesize relevant history from patients and families, and their communities.3) Listen effectively. 4) Discuss appropriate information with patients and families, and the health care team.

Specific Requirements

1) In order to achieve these objectives the resident must develop the ability to: Inform patients and families about their condition at an appropriate and

understandable level.

Be sensitive and respond appropriately to issues of gender, culture and ethnicity indealing with patients and families.

Write a preliminary report of operations on chart.

Dictate concise, clear descriptions of operations.

Write clear consultation note/discharge summary/clinic note.

Prepare and present ward and intensive care unit (ICU) rounds in an organizedmanner.

Participate actively in scheduled rounds.

Collaborator

General Requirements 1) Consult effectively with other physicians and health care professionals. 2) Contribute effectively to other interdisciplinary team activities.

Specific Requirements 1) In order to achieve these objectives the resident must develop the ability to:

Work with ward, ICU, operating room and expanded role nurses to manage patientsappropriately.

Identify social, rehabilitative, dietetic concerns with patients and consult appropriateallied health professionals.

Consult and work with medical specialists appropriately.

Assist allied health professionals through active participation in their training and educational rounds.

Manager

General Requirements 1) Utilize resources effectively to balance patient care, learning needs, and outside activities.2) Allocate finite health care resources wisely. 3) Work effectively and efficiently in a health care organization. 4) Utilize information technology to optimize patient care, life-long learning and other

activities.

COMPETENCIES


Specific Requirements 1) In order to achieve these objectives the resident must develop the ability to:

Understand the importance of mechanisms to safely utilize resources in a cost-effective manner to benefit all patients.

Recommend practices to effectively utilize resources including undertaking studies toassess effectiveness of standard care procedures.

Health Advocate

General Requirements 1) Identify the important determinants of health affecting patients. 2) Contribute effectively to improved health of patients and communities. 3) Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements 1) In order to achieve these objectives the resident must understand the:

Principles and data supporting primary and secondary prevention of coronary arterydisease and other thoracic diseases;

Triage system for the surgical wait list; its rationale, and how patients are added orupgraded; and the

Value of outcomes research for surgical procedures.

2) In order to achieve these objectives the resident must develop the ability to:

Assess all patients for risk factors for cardiovascular/cardiothoracic disease and advise appropriate interventions.

Utilize appropriate lipid lowering agents correctly.

Participate in outcomes research and assist in disseminating resulting information.

Develop and support constructive relationships with hospital administrators; Regional,Provincial and Federal Government Agencies and Representatives.

Support the activity of local and national organizations promoting health advocacy.

Scholar

General Requirements 1) Develop, implement and monitor a personal continuing education strategy. 2) Critically appraise sources of medical information. 3) Facilitate learning of patients, house staff/residents and other health professionals. 4) Contribute to the development of new knowledge.

COMPETENCIES


Specific Requirements 1) In order to achieve these objectives, the resident must:

Recognize gaps in knowledge and develop strategies to correct this by self-directedreading and consulting with other professionals.

Contribute knowledge learned to service rounds.

Understand principles and practice of basic and applied research, including thescientific method, design and conduct of clinical trials, critical appraisal of literatureand the use of statistics.

Understand need to incorporate gender, cultural and ethnic perspectives in researchmethodology.

Prepare and present scheduled rounds.

Participate actively in scheduled morbidity and mortality conferences.

Actively participate in journal club.

Prepare and present clinical research papers at peer-reviewed meetings, and publishin medical literature.

Participate effectively in teaching fellow professionals, including junior house staff.

Professional

General Requirements 1) Deliver highest quality care with integrity, honesty and compassion. 2) Exhibit appropriate personal and interpersonal professional behavior. 3) Practice medicine ethically consistent with the obligations of a physician.

Specific Requirements In order to achieve these objectives, the resident must develop the ability to:

Deliver care with integrity, honesty and compassion.

Understand the professional, legal, and ethical codes to which physicians are bound.

Recognize self-limitations and seek outside assistance where appropriate.

At all times, function professionally at an independent consultant level.

Be sensitive to and respond appropriately to patients of different social status, ethnicgroups, age and gender.

ROTATION-BASED TRAINING OBJECTIVES


ROTATION BASED TRAINING OBJECTIVES

General Surgery

General Objectives The rotation in General Surgery is designed to give the trainee the first exposure to surgery and basic surgical principles as they relate to preoperative assessment, evaluation, operating room function, postoperative care, and wound management. Basic technical skills related to instrumentation, knot tying and incisions need to be acquired. A further overall objective of the rotation in General Surgery is to become familiar with the general surgical complications and their management as they may relate to cardiac surgical patients.

Specific Objectives Knowledge 1) Wound complications and management.2) Surgical nutrition.3) Management of comorbid medical conditions in the surgical patient, such as diabetes,

hypertension, renal and respiratory failure. 4) Response to injury and surgical trauma, including fluid management.5) Indications and contraindications of open versus minimally invasive surgery.6) Basic anatomy of the alimentary tract and intraabdominal organs.7) Understanding the differences in suture material and their use.8) Specific disease states, including history of presentation, pathophysiology and

management of cholecystitis, calculous and acalculous, pancreatitis, gastrointestinal bleeding from peptic ulcer disease, gastritis, esophagitis, colonic lesions, and ischemic bowel.

9) Acute abdomen and the requirement for emergency surgery and/or general surgicalconsultation.

10) Clear ability to perform an adequate history and review of systems in the surgical patient.

Technical Skills 1) Be able to identify and use basic instrumentation used in laparotomy and laparoscopy.2) Be able to perform abdominal incisions, including laparotomy incision, appendectomy

incision, as well as an open cholecystectomy incision (both opening and closing). 3) Be able to insert safely laparoscopic devices through the abdomen.4) Be able to handle tissues appropriately.5) Be able to perform various knot tying techniques and closure [2-handed ties, 1-handed tie,

running closure, vertical mattress, horizontal mattress, subcuticular]. 6) Be able to perform with supervision the following procedures: laparoscopic

cholecystectomy, open and closed inguinal hernia repair, appendectomy, varicose vein stripping, excision of nodular and cystic lesions of the skin.

Trauma Surgery

General Objectives On completion of the rotation, the resident will become familiar with and be able to manage and apply the principles of trauma care to victims of blunt trauma and penetrating injury. The resident will become familiar with the management of primary resuscitation, primary survey and secondary survey and be able to plan appropriate investigations and therapy.



Specific Objectives Knowledge 1) Epidemiology of blunt and penetrating trauma. 2) Principles of field triage.3) Patterns of injury occurring in motor vehicle accidents with and without seat belts, as well

as various types of gunshot wounds to the chest. 4) Pre-hospital emergency medical systems and pre-hospital cardiopulmonary resuscitation.5) Initial assessment of the trauma patient, including all of the principles of primary

resuscitation, primary survey, secondary survey. 6) Airway management in the trauma patient, including methods of securing an airway with

C-spine precautions. 7) Management of shock and its etiology, specifically hemorrhagic, cardiac [tamponade], and

neurogenic. 8) Principles of auto-transfusion and massive transfusion.9) Indications and application of Emergency Department thoracotomy.10) Interpretation of chest radiographs and computed tomographic (CT) scans of the chest.11) Appropriate sedation techniques used in the trauma victim.12) Specific injuries, including thoracic trauma. 13) Injuries to the chest wall and principles of reconstruction.14) Management of the trachea, bronchus and esophagus.15) Management of penetrating injury to the heart.16) Management of injury to thoracic great vessels through penetrating or blunt trauma.17) General knowledge and the management of injuries to the intraabdominal organs.18) General knowledge, management and principles of extremity injury, including principles of

fixation and vascular injury of the extremity.

Clinical Skills 1) Be able to assess the trauma victim from entry into the Emergency Room applying ATLS

protocol. 2) Be able to coordinate the management of the trauma victim using members of the Trauma

team and allied health care professionals. 3) During resuscitation, be able to perform the following:

Maintain airway in patients with C-spine injury

Central line insertion

Chest tube insertion

Diagnostic peritoneal lavage (DPL) 4) Management of shock, including pericardiocentesis.5) Be able to perform Emergency Department thoracotomy in appropriate situations.6) Be able to ensure safe transport to radiological services and operating room.7) During secondary survey, be able to initially manage extremity fractures, including

appropriate methods of mobilization and coverage. 8) Be able to evaluate abdominal and chest trauma.9) Be able to perform emergency laparotomy and/or sternotomy, as well as thoracotomy in

the operating room. 10) General appreciation of the techniques involved in exposure of the great vessels, including

axillary and subclavian arteries. 11) General appreciation and technical ability to expose intrathoracic organs through

thoracotomy, clamshell or sternotomy incisions.



12) Be able to control intrathoracic or intraabdominal hemorrhage using packing and digitalpressure, and appreciation of the various techniques used to treat cardiac lacerations, as well as great vessel injuries.

13) Appreciation and technical ability related to exposure of the abdominal aorta.14) Appreciation of the general principles and ability to manage splenic and liver lacerations.

Thoracic Surgery

General Objectives 1) Provide scientifically based, comprehensive and effective diagnosis and management for

patients with thoracic disease.2) Communicate effectively with patients, their families and medical colleagues (particularly

referring physicians), and other health care professionals.3) Counsel patients and others on aspects of prevention of all thoracic diseases, including risk

factors, and genetic and environmental concerns. 4) Maintain complete and accurate medical records. 5) Effectively coordinate the work of the health care team. 6) Be proficient in professional and technical skills related to thoracic surgery.7) Critically assess the thoracic literature as it relates to patient diagnosis, investigation and

management.

Specific Objectives Knowledge 1) Anatomy, embryology, physiology and pathology of the lung, pleura, tracheobronchial

system, mediastinal esophagus and chest wall.2) Natural history of treated and untreated surgical diseases of the non-cardiovascular

thoracic organs, including benign and malignant lung and esophageal diseases, trauma,congenital anomalies, infection and their complications.

3) Pharmacology, indications for and complications of drugs commonly used in the specialty.4) General principles of preoperative assessment, anesthetic management, postoperative

monitoring and management of thoracic surgical patients.5) Principles of hemostasis and nutrition, including intravenous hyperalimentation, as they

apply to the specialty.6) Respiratory failure and support, including ventilators and membrane oxygenators.7) Oncology, staging of cancers, tumor immunology, adjuvant chemotherapy, radiotherapy

and immunotherapy in thoracic malignancies.8) Interpretation, indication and complications of invasive and non-invasive diagnostic

methods, including pulmonary function tests, esophageal function tests and diagnosticimaging.

9) Role of endoscopy, thoracoscopy, laser and video-assisted (VATS) technologies in thediagnosis and management of thoracic surgical patients.

10) Knowledge of lung transplantation, including organ preservation for transplantation,immunology and pathophysiology of allograft rejection, immunosuppression and itscomplications.



Clinical Skills 1) Be able to obtain a complete history from the patient and a collateral history where

necessary. 2) Be able to perform an appropriate physical examination. 3) Be able to understand appropriate laboratory, functional and imaging procedures as they

relate to pulmonary, esophageal and mediastinal disease. 4) Be able to formulate an appropriate differential and provisional diagnosis. 5) Outline an appropriate plan of laboratory investigation. 6) Outline an appropriate therapeutic plan. 7) Be able to exhibit appropriate clinical judgment in outlining a differential diagnosis and an

investigative and therapeutic plan, taking into account matters such as the patient’s age, general health, risk and cost of investigative procedures, risk and cost of therapeutic interventions, and epidemiology of the diseases.

Technical Skills 1) Technical and clinical competence in all procedures commonly performed in general

thoracic surgery, including the ability to select the procedure appropriate to the clinical situation, and to recognize his/her limitations.

2) Be able to perform and understand the indications for all thoracic incisions, including median sternotomy, posterolateral thoracotomy, anterolateral thoracotomy, and emergency room thoracotomy.

3) Be able to perform a full range of pulmonary resections, including lobectomy, pneumonectomy and wedge resections, and institute appropriate pleural drainage for each procedure.

4) Be able to perform a wide range of procedures for esophageal malignancy, including Ivor-Lewis esophagectomy, transhiatal esophagogastrectomy, and bypass procedures. This will require the ability to provide anatomic exposure in the neck and abdomen.

5) Be able to understand and perform procedures for restoration of normal esophageal motility and gastro-esophageal competence with abdominal and thoracic procedures, including video-assisted thoracoscopy.

6) Be able to resect mediastinal tumors by the anatomically indicated procedure, including cervical and thoracic approaches.

7) Be able to perform reconstruction procedures on the diaphragm by an abdominal or thoracic approach.

8) Experience in laser surgery as applied to the specialty. 9) Competence in the critical care of thoracic surgical patients in the intensive care unit. 10) Competence in the operative and non-operative management of all aspects of thoracic

trauma.



Vascular Surgery

General Objectives Following the rotation in Vascular Surgery, the resident will become familiar and have a working knowledge of the major aspects of vascular disease affecting the carotid, aorta and lower limbs. The resident will have a working knowledge of the various medical and surgical treatments of vascular disease, including endovascular therapy. The resident will also appreciate that vascular disease forms a large component of the care of the cardiac surgical patient and appropriate care of the vascular abnormalities will result in good surgical care and outcomes.

Specific Objectives Knowledge At the end of the rotation, the resident will have sufficient knowledge in the following domains: 1) Anatomy and physiology of the arterial system, including the carotid, the aorta and the

peripheral arterial vascular tree. 2) Pathophysiology of atherosclerosis and natural history of carotid artery disease, aortic

occlusive and non-occlusive disease, as well as peripheral arterial disease. 3) Coagulation cascade and vascular biology.4) Medical treatment of carotid artery disease and peripheral artery disease, as well as the

complications thereof, including chronic ulcers and diabetic foot. 5) Medical management of the disease affecting vascular patients, such as coronary artery

disease, diabetes, hypertension and renal dysfunction. 6) Indications and contra-indications of surgical interventions for carotid artery, aortic

aneurysm and non-occlusive disease, and chronic lower extremity occlusive disease. 7) Indications and contraindications to endovascular therapy for peripheral artery disease,

aortic disease and carotid disease. 8) Use of fluoroscopy and principles of radiation safety.9) Results of conduit selection, including biological and synthetic grafts, as well as

endovascular grafts. 10) Results of procedures over time. 11) Principles and management of vascular trauma.12) Diagnosis and investigative modalities used in Vascular Surgery, including

plethysmography, angiography and Doppler imaging.

Clinical Skills 1) Be able to obtain an adequate history and physical examination for the vascular patient

with special emphasis on identifying carotid bruits, aneurysms of the abdomen, and femoral, popliteal, posterior tibial and dorsalis pedis pulses.

2) Be able to identify acute ischemic syndromes of the cerebral, abdominal and peripheralcirculation.

3) Be able to interpret diagnostic modalities, such as plethysmography, angiography and Doppler ultrasound in the treatment and management of vascular patients.

Technical Skills -Junior level 1) Be able to insert central venous and arterial access.2) Be able to perform conduit harvesting, especially of the lower and upper extremities.3) Be able to expose the femoral artery, axillary artery, and carotid artery.4) Be able to perform a laparotomy, as well as closure of laparotomy.



5) Be able to assist in intraabdominal surgery.6) Be able to perform vascular anastomoses.7) Become familiar with basic fluoroscopic techniques, including safety practices.8) Become familiar with the general approach to endovascular procedures, including femoral

artery exposure and principles of guidewire manipulation in the arterial tree.

Technical Skills -Senior level 1) Be able to expose safely and adequately in an open fashion the carotid artery, the axillary

artery, the brachial artery, the femoral artery and femoral vein, and the popliteal artery. 2) Be able to open the abdomen and expose the infrarenal aorta safely and adequately for

open aortic aneurysm repair. 3) Be able to understand the principles of a retroperitoneal approach.4) Be able to perform thrombectomy on an acutely ischemic upper extremity and lower

extremity using balloon thrombectomy and surgical bypass. 5) Be able to perform patch angioplasty of the femoral artery and the profunda.6) Be able to perform fem-fem crossover graft, including appropriate sizing of graft and

anastomosis. 7) Be able to perform at least the proximal anastomosis of the fem-pop distal graft, and

perhaps the popliteal portion of the anastomosis. 8) Be able to use both an in situ and reverse saphenous vein, as well as synthetic conduits for

this procedure. 9) Be able to perform an axillary anastomosis, and understand in assisting the principles of an

axillary-femoral bypass. 10) Be able to assist in a thoracoabdominal aneurysm repair, and perform left heart support

during the procedure, such as left atrial-femoral artery Biomedicus pump support. 11) Be able to cannulate the femoral artery and position catheters for endovascular stenting.12) Be able to evaluate the appropriateness of placing an endovascular stent, and at least

assist in the deployment of endovascular stents in the abdominal aorta and thoracic aorta. 13) Become completely familiar with all of the complications related to endovascular stent

placement and its therapeutic management such as limb ischemia, bleeding, migration, aortic rupture, and organ ischemia, specifically subclavian occlusion.

14) Become familiar with the newer stenting procedures, such as carotid artery stenting, and ifpossible, assist in one of them. Understand the principles of carotid stenting, including the indications and contraindications.

Intensive Care Unit (ICU)

General Objectives On completion of this rotation, the resident will become familiar and be competent in the management of postoperative cardiac surgical patients in the Critical Care Unit. This rotation will be the basis for critical care management overall, which will be further developed in the senior rotations. This rotation, however, is the first direct hands-on experience with the treatment of critically ill patients. The resident will also appreciate the crucial role Critical Care plays in the overall management and outcome of the cardiac surgical patient. Resident’s training within the unique critical care environment must respect the rights of the patients and families and acknowledge the importance of age, gender, culture and ethnicity when decisions are made regarding level of care.



Specific Objectives Knowledge 1) Demonstrate detailed knowledge of the general and specialist aspect of critical illness.2) Demonstrate competencies in the safe application of equipment, careful monitoring and

use of drugs in the coordinated provision of multidisciplinary care.3) Demonstrate the ability to recognize, resuscitate and stabilize patients at risk of

cardiopulmonary arrest or other life threatening disturbances following cardiac surgery.4) Demonstrate basic understanding of physiology, pathophysiology and pharmacology as

they pertain to the critically ill patient about to undergo cardiac surgery or following a cardiac surgical procedure.

5) Demonstrate knowledge of the following:

Cardiovascular Dysfunction:o Ability to recognize the need for emergency life support and embark on a

diagnostic and management program.o Detailed knowledge of advanced cardiac life support techniques. o Hemodynamic monitoring.o Pathophysiology and treatment of cardiac failure, including the pharmacology of

drugs used to treat these entities.o Basic and complex cardiac arrhythmia, including pharmacologic and electrical

management. o Shock syndromes.o Heart-lung interactions.o Acute valvular heart disease.o Acute coronary syndromes.o Hypertensive emergencies.o Postoperative cardiogenic shock, including indications for intraaortic balloon

pump counterpulsation.

Respiratory Dysfunction:o Ability to determine the presence of respiratory failure and provide for its

emergency support.o Demonstrate knowledge of the normal anatomy, the respiratory system,

physiology of gas exchange, including lung and chest wall mechanics.o Demonstrate knowledge of chest imaging of the ICU patient.o Pathophysiology of diseased states leading to respiratory failure.o Types of respiratory failure.o Principles and theory of mechanical ventilation support.o Respiratory problems and their management following cardiac surgical

interventions, such as hemothorax, pneumothorax, lung edema, reversible airwaydisease, and COPD.



Neurological Dysfunction: o Ability to recognize problems in a patient with a central nervous system crisis

and/or altered level of consciousness, and carry out appropriate neurological examination with appropriate and diagnostic supportive measures.

o Demonstrate the knowledge of stroke and stroke syndromes following cardiac surgery [embolic, hemorrhagic, edema, drug-related].

o Demonstrate knowledge of the toxic, metabolic, structural and infectious causes of altered levels of consciousness.

o Investigation of systemic metabolic consequences. o Knowledge of the environmental and drug-related psychopathology associated

with critical illnesses [anxiety, sleep disorder, hallucinations, and withdrawal].

Dysfunction: o Ability to recognize the problem of a patient with oliguria or other evidence of

advanced renal failure and institute measures to preserve renal function, including precise diagnosis and support measure.

o Demonstrate the knowledge of the pathophysiology and management of both medical and surgical acute renal failure, pre-renal, renal and post-renal failure.

o Pharmacodynamics and toxins. o Perioperative issues. o Pharmacological management and potential complications of the renal failure

patient. o Demonstrate knowledge of basic renal support, including CVVH.

Gastrointestinal Dysfunction: o Ability to evaluate the nature of the illness of a patient who presents with

gastrointestinal crisis and institute immediate life-saving support. o Demonstrate the knowledge of the etiology, diagnosis and management of the

acute abdomen. o Etiology, diagnosis and management of viscus dysfunction and perforation. o Etiology, diagnosis and management of upper and lower G.I. bleeding. o Good understanding of the pathophysiology of ischemic bowel, pancreatitis, and

acalculous cholecystitis.

Hematological Disorders: o Ability to recognize the problem of a patient with a thrombotic or thrombolytic

disorder, bleeding, thrombocytopenia or anemia. o Demonstrate the knowledge of the pathogenesis and management of

thrombocytopenia and anemia. o Demonstrate the knowledge of the coagulation sequence, fibrinolytic pathway

and their associated disorders, and specifically the disorders related to cardiopulmonary bypass and consumption of coagulation factors.

o Demonstrate knowledge of hematological support for the bleeding patient, specifically the bleeding cardiac surgical patient, including the appropriate use of pro-coagulant medication, blood transfusions, plasma, cryoprecipitate, platelets, and factor 7 concentrate.

Metabolic and Endocrine Disorders: o Ability to recognize the nature and severity of the problem of a patient with

metabolic, endocrine or fluid electrolyte abnormalities. o Demonstrate the knowledge of the diagnosis and management of fluid and/or

electrolyte disturbances, including the diagnosis and treatment of acid-base disorders.



Septic Illness:o Ability to recognize the infective nature of the condition of a patient with septic

illness and institute immediate life-saving procedures. o Demonstrate knowledge of the pathophysiology of sepsis and septic shock, the

epidemiology of host specific infectious diseases, preventive infection control techniques, including antibiotic prophylaxis, the pharmacology indication, complications and interaction of the usual microbial agents, and the effect of sepsis on multi-organ dysfunction.

Nutritional Support:o Evaluate the nutritional status of the critically ill patient, identify deficiencies and

ongoing losses, and develop a management strategy for either enteral or parenteral nutrition.

o Demonstrate the knowledge of fluid compartments and fluid caloric requirements in the critically ill patient.

o Demonstrate the knowledge of the techniques and laboratory tests used to evaluate nutritional status, and the methods for assessing basal nutritional expenditure and monitoring effectiveness.

o Appreciate the indications, limitations, methods and complications of enteral and parenteral nutritional therapy.

Transportation:o Demonstrate the knowledge of the communication triage and preparation prior to

and during transport from the ICU to Radiology or to the Ward. o Demonstrate the unique monitoring and management problems associated with

transport. o Understand the role of paramedical personnel and determine the need for

physician accompaniment.

In addition to the before-mentioned objectives, the resident should become an expert in the following domains in the management of the postoperative cardiac surgical patient: 1) Etiology, diagnosis and management of the support of the cardiovascular system due to

shock [cardiogenic, non-cardiogenic, tamponade]. 2) Etiology, diagnosis and management of the bleeding postoperative cardiac surgical patient.3) Diagnosis, management and treatment of postoperative dysrhythmias and arrhythmias, as

well as ST segment elevation and depression.

Technical Skills: Demonstrate the proficiency of the following technical skills: 1) Airway:

Be able to assess and maintain an airway, orotracheal intubation.

Indication for a tracheostomy tube insertion, the replacement of a pre-existingtracheostomy tube, cricothyroidotomy, and indication for urgent surgical airways.

Be able to ventilate using bag and mask.

Application of conventional positive pressure mechanical ventilation as well as non-invasive ventilation.

Application of capnography.

Application of pulse oximetry.

Ventilation weaning techniques.



Circulation.

Insertion of arterial lines, central venous lines, zeroing and calibration of transducers.

Application and maintenance of pulmonary artery catheters.

Be able to perform cardiac output measurements and other derived calculations frompulmonary artery catheter, ECG interpretation, defibrillation, electrocardioversion,cardiac overdrive pacing, temporary transvenous pacemaker, and temporarytranscutaneous pacemaker.

Prevention and management of air embolism.

Knowledge and maintenance of intra-aortic devices, such as intra-aortic balloon pump.2) Renal:

Insertion of temporary hemodialysis catheter.

Indication of continuous renal replacement therapy.3) Gastrointestinal:

Ability to insert a post-pyloric feeding tube.4) Nutrition:

Ability to write out a nutritional plan.5) Transport:

Ability to organize and supervise an intra-hospital transfer, as well as an inter-hospitaltransfer.

Cardiac Catheterization

General Objectives On completion of the rotation, the resident will become familiar with cardiac catheterization, angiography and intervention in the management of cardiac patients. This rotation will form the basis for angiographic interpretation, hemodynamic evaluation of cardiac lesions that will become important when you embark on your R-IV and R-VI rotations in Cardiac Surgery, and as you start practice. The resident will also appreciate the collaborative role cardiologists and cardiac surgeons play in deciding revascularization therapies.

Specific Objectives Knowledge 1) Principles underlying the utilization of cineangiographic equipment.2) Principles of radiation safety and radiation control.3) Indications for cardiac catheterization and intervention using angioplasty and/or stents.4) Complications and risks of various cardiac catheterization procedures, including diagnostic

catheterization either via the femoral artery or radial artery, stents and angioplasty.5) Indications and contraindications to emergency revascularization in the Cardiac

Catherization Laboratory in patients with evolving myocardial infarction.6) General monitoring techniques such as pressure monitoring, hemodynamic monitoring

and cardiac output measurements.7) Hemodynamic measurements at cardiac catheterization, including the evaluation of

stenotic and regurgitant valves and shunt fractions.8) Principles of endomyocardial biopsy.9) Indications and contraindications for balloon valvuloplasty both of the aortic valve and

mitral valve.10) Angiographic anatomy of the coronary circulation, including normal and abnormal

coronary anatomy.



11) Evaluation of stenotic atherosclerotic lesions of the coronaries.12) Appropriate use of antiplatelet agents and anticoagulant agents used in the Cardiac

Catheterization Laboratory, specifically on their side effects on platelet function, coagulation and their potential risk when patient goes to cardiac surgery.

Clinical and Technical Skills: 1) Be able to cannulate femoral artery, femoral vein and the radial artery for cardiac

catheterization access.2) Be able to move catheters in the vascular system safely from the femoral artery to the

aortic valve, and from the radial artery to the aortic valve.3) Be able to inject contrast agents into the coronary circulation for diagnostic coronary

angiography. 4) Be able to cross the aortic valve safely to perform hemodynamic measurements of the left

ventricle.5) Be able to treat ventricular arrhythmias as they occur during catheter manipulation.6) Be able to intubate both the right and left coronary tree with guidance and supervision.7) Be able to assist in the localization of coronary lesions for angioplasty and stenting.8) Be able to apply safe practices of radiation control.9) Be able to interpret angiographic anatomy from coronary angiography.10) Be able to interpret hemodynamic data as it is presented during right and left heart

catheterization.11) Specifically, be able to interpret data as it pertains to aortic stenosis, aortic regurgitation,

mitral stenosis and mitral regurgitation in their pure forms.

Echocardiography

General Objectives: Upon completion of the rotation, the resident will become familiar with the indications and use of transthoracic and transesophageal echocardiography in the management of the cardiac surgical patient. Although most of the patients will not have had cardiac surgery nor will be undergoing cardiac surgery during this rotation, it is important to understand the information, which can be obtained via echocardiography, the subtleties and nuances associated with the procedure. This allows you to better understand the reports, as well as to interpret and apply them on your own cardiac surgical patients.

Specific Objectives Knowledge: 1) Indications and contraindications of transesophageal and transthoracic echocardiography.2) Appreciate the differences in the types of probes used for echocardiography, including the

different types of frequencies used.3) Doppler principles used in echocardiography, including the Bernoulli and continuity

equations.4) Anatomy of the heart viewed in short and long axis views.5) Diagnostic criteria for left and right atrial enlargement, left ventricular hypertrophy, aortic

stenosis, mitral stenosis, aortic regurgitation, and mitral regurgitation.



6) Measurement of ventricular function, as well as ventricular dimension.7) Evaluation of aortic pathology including size, aneurysmal dilatation, and dissection.8) Indications for and use of exercise stress echocardiography and Dobutamine stress

echocardiography.

Technical Skills: 1) Be able to, with appropriate guidance using transthoracic echocardiography, evaluate the

heart in short and long axis, and identify the four chambers. 2) Be able to evaluate grossly ventricular function.3) Be able to evaluate grossly aortic valve and mitral valve pathology.

Junior Adult Cardiac Surgery

General Objectives: On completion of this rotation, the junior cardiac surgery resident will become familiar with the presentation, preoperative preparation, surgical management, and postoperative care of the cardiac surgical patient. This rotation will form the basis for further knowledge and technical skills training in Cardiac Surgery.

Specific Objectives: Knowledge: 1) Acquisition of the principles essential to the care of cardiac surgical patients, including

recognition and management of concomitant medical conditions of the cardiac surgical patient, such as diabetes, renal dysfunction, respiratory problems, cerebrovascular disease, as well as peripheral vascular disease.

2) Recognition and management of vascular, neurological and general surgical complicationsin cardiac surgical patients, including peptic ulcer disease, hepatobiliary disease [pancreatitis, acalculous cholecystitis], limb ischemia, colonic ischemia.

3) Recognition and use of various risk assessment scores prior to surgery, such as theParsonnet score, STS score, EuroScore.

4) Recognition and use of various thoracic incisions for the surgical approach to conduitharvest and vascular access.

5) Wound complications and their management, including sepsis, causes, prevention, presentation and treatment.

6) Management of surgical nutrition.7) Anticoagulation, indications, complications, management of heparin-induced

thrombocytopenia, as well as the use of low molecular weight heparin and coumadin. 8) Use of cardiac medications, including inotropes and antiarrhythmics for the treatment of

atrial fibrillation. 9) Causes and management of postoperative atrial fibrillation, including all forms of

treatment [electrical cardioversion, chemical cardioversion with various anti-arrhythmic agents].

10) Thorough understanding, recognition and management of medical conditions, includingdiabetes, renal dysfunction, respiratory problems, cardiovascular disease as well as peripheral vascular disease.

11) Vascular, neurological and general surgical complications in cardiac surgical patients,including peptic ulcer disease, limb ischemia, colonic ischemia.



12) All of the major complications of cardiac surgical patients, including postoperativehemorrhage, tamponade, low output state, myocardial infarction, postoperative sepsis,respiratory dysfunction, neurological dysfunction, and vascular disease.

13) Wound complications, including drainage, re-wiring and flapping. 14) Pathophysiology of cardiopulmonary bypass, including its deleterious effects and

catastrophic complications of cardiopulmonary bypass.15) Mechanisms of myocardial injury and their prevention during cardiac surgical procedures.16) Different types of myocardial protection techniques, including hypothermia, cardioplegia

and substrates.17) Anatomy of coronary circulation as seen in coronary angiography.18) Ability to diagnose coronary pathology.19) Ability to diagnose pathology using standard imaging techniques for myocardial ischemia,

including electrocardiogram, stress test, coronary angiography, nuclear medicine test, andstress echocardiography.

20) Ability to manage both medically and surgically coronary insufficiency, including theindications and contraindications for myocardial revascularization.

21) Ability to manage patients with unstable angina prior to surgery.22) Ability to manage patients in acute myocardial infarction with its mechanical

complications, including VSD, cardiac rupture and mitral insufficiency.23) Ability to manage patients preoperatively with valvular heart disease, including those with

aortic regurgitation and stenosis, mitral regurgitation and stenosis, and tricuspidregurgitation and stenosis.

24) Indications and contraindications to surgical management in all types of valvularpathology.

25) Various techniques of valve surgery, including mitral valve repair and indications for aorticroot enlargement.

26) Management of the traumatic chest injury, including diagnosis and therapy for blunt andpenetrating trauma to the chest, specifically aortic disruption, cardiac stab wounds, and pulmonary injury.

Clinical Skills: 1) Be able to take an appropriate history and physical of the cardiac surgical patient paying

close attention to risk factors, comorbid conditions, and appropriate preoperativemanagement.

2) Be able to recognize and treat wound complications, including infections, dehiscence,mediastinitis, and prescribe appropriate prophylactic measures for infection prevention.

3) Be able to institute and monitor surgical nutrition via enteral or parenteral routes.4) Be able to manage postoperative atrial fibrillation.5) Be able to manage patients with concomitant medical conditions, including diabetes, renal

failure, respiratory insufficiency, and other manifestations of atherosclerotic disease.

Technical Skills: 1) Management of the emergency situation in the ward, including the ability to perform

adequate cardiopulmonary resuscitation, non-invasive airway management, central lineplacement via subclavian, jugular or femoral vein.

2) Be able to perform cardioversion or defibrillation using external defibrillator.3) Be able to attach external pace wires to pacemaker and start the various appropriate

forms of pacing, including AAI, DDD, DVI, and VVI.4) Be able to manage wound infections in the ward by opening, packing and debridement.



5) Be able to insert chest tubes to awake patients, both for pneumothorax and hemothorax.6) Be able to perform thoracentesis for diagnostic and therapeutic purposes. 7) Be able, with assistance, to perform pacemaker implantation, including obtaining access,

threading guide wire, lead and attaching battery.8) Be able to open and close a primary sternal incision.9) Be able to perform conduit harvest of the greater saphenous vein, as well as opening and

closing the incision.10) Be able to perform first assistance on cardiac surgical procedures, including assisting on

cannulation, coronary revascularization, valvular interventions, as well as aortic surgery.11) Be able to set up the tubing for myocardial protection, including the use of antegrade and

retrograde cardioplegia, as well as the octopus. 12) Be able to perform primary sternal opening and closure without difficulty.13) Be able to perform mammary harvesting of the left internal mammary artery.14) Be able to harvest left radial artery, if needed, without difficulty.15) Be able to institute cardiopulmonary bypass in first time cardiac surgical patients

undergoing coronary bypass surgery, as well as valvular surgery.16) Be able to insert antegrade cardioplegia techniques using hand-held catheters, as well as

indirect and direct establishment of retrograde coronary sinus catheter intubation.17) Be able to inspect the aorta for atherosclerotic disease using palpation and interpretation

of transesophageal echocardiographic material.18) Be able to correlate preoperative coronary angiography with intraoperative coronary

anatomy.19) Be able to perform proximal anastomosis of reverse saphenous vein grafts onto aorta, as

well as distal anastomoses on appropriate large distal coronary arteries.20) Be able to wean from cardiopulmonary bypass with special attention to temperature, ECG,

acid base balance, hematocrit, perfusion pressure.21) Be able to recognize need for further inotropic support and/or intraaortic balloon pump.22) Be able to insert intraaortic balloon pump, either percutaneously or through femoral

artery cut-down. 23) Be able to time aortic balloon pump appropriately.24) Be able to remove intraaortic balloon pump safely.25) Be able to recognize tamponade and open patient appropriately.26) Be able to set-up for aortic and mitral valve surgery, including appropriate incisions on the

aorta and in the left atrium.27) Be able to inspect aortic and mitral valve pathology.28) Be able to obtain hemostasis following surgical procedure.29) Be able to close sternal opening safely and securely.30) Be able to first assist in all other complex cardiac surgeries, including redo, combined

valvular heart disease, and combined coronary and valvular disease.

Cardiopulmonary Bypass

Knowledge: 1) Use and pathophysiology of cardiopulmonary bypass, including deleterious effects.2) Be able to list catastrophic complications of cardiopulmonary bypass.



Clinical Skills: 1) Recommend appropriate method of cardiopulmonary bypass institution, including

cannulation, temperature management.2) Recognition of catastrophic complications and their management, including air embolism,

mechanical failure of cardiopulmonary bypass pump and clotting on cardiopulmonarybypass.

Myocardial Protection

Knowledge: 1) Understand the mechanisms of myocardial injury and their prevention during cardiac

surgical procedures.2) Understand the different types of cardioplegia and myocardial preservation techniques,

including antegrade and retrograde cardioplegia, cardioplegic composition, temperature,and added substrates.

Clinical Skills: Recognize the need for myocardial protection and recommend the appropriate methods to achieve it.

Ischemic Heart Disease

Knowledge: 1) Principles and management of patients with ischemic heart disease.2) Recognize the anatomy and physiology of coronary circulation effects of obstruction.3) Appreciate the cardiac anatomy as outlined in the coronary angiography.4) Understand the principles and use of imaging techniques for myocardial ischemia,

including electrocardiogram, stress test, coronary angiography, nuclear medicine scans,and stress echocardiography.

5) Understand both the medical and surgical management of coronary insufficiency, includingindications for intervention and outcome for revascularization.

6) Principles of management of unstable angina and the principles of management of acutemyocardial infarction with its mechanical complications [VSD, cardiac rupture, mitralinsufficiency].

7) Both primary and secondary prevention of ischemic heart disease.

Clinical Skills: 1) Be able to use and interpret results of coronary angiography appropriately.2) Be able to use and interpret appropriately the tests for myocardial ischemia.3) Recognize and manage acute and chronic coronary ischemia, especially preoperatively, and

on the occasion that it would occur postoperatively.4) Recommend appropriate timing of surgical strategies for coronary artery disease.5) Be able to estimate operative risk using appropriate scoring systems and literature review.

Valvular Heart Disease

Knowledge: 1) Surgical management of patients with valvular heart disease, including the indications and

contraindications related to repair or replacement of the aortic valve, mitral valve, andtricuspid valve.

2) Anatomy of the cardiac valves and relationships to adjacent structures.



3) Natural history of all forms of valvular heart disease.4) Various surgical approaches to cardiac valves and the advantages and disadvantages of

available valve repair, methods and prosthetic implantations.5) Various techniques of valve surgery, including the principles of mitral valve repair and

aortic root enlargement.6) Guidelines for reporting valve results, including time-related multi-variable analysis of

morbidity and mortality.

Clinical Skills: 1) Be able to interpret the hemodynamic results at heart catheterization.2) Be able to understand echocardiographic criteria for severity of aortic and mitral valve

pathology.3) Recommend the appropriate timing for surgical intervention.4) Recommend appropriate valve operation and prosthesis selection.5) Recognize complications of valve surgery, including residual obstruction or insufficiency

and the rate of infection and thrombosis and degeneration over time.

Thoracic Aortic Pathology

Knowledge: 1) Anatomy of the aorta, including its intra-thoracic branches and related intra-thoracic

structures.2) Pathophysiology of aortic disease, including atherosclerotic disease, Marfan’s and cystic

medial necrosis.3) Pathophysiology of thoracic and thoracoabdominal aortic aneurysms and dissections.4) Natural history of aortic disease vis-à-vis risk of dissection and rupture according to size.5) Use and principles of various scanning and diagnostic techniques for acute aortic

dissection.6) Indications for medical and surgical intervention.7) General principles of surgical repair and different types of conduits used, as well as

techniques for preventing brain and spinal cord damage.

Clinical Skills: 1) Recognize and diagnose thoracic aortic disease emergencies, such as rupture and aortic

dissection.2) Recommend medical therapy, as well as the timing of surgical intervention.

Transplantation and Cardiac Failure

Knowledge: 1) Principles and management of patients with end-stage heart failure, including the

pathophysiology and natural history.2) Medical therapy and pharmacology of available agents for heart failure.3) Indications for surgical therapy for heart failure, including conventional revascularization,

valve surgery, resynchronization therapy, left ventricular reduction, cardiomyoplasty,transplantation, as well as mechanical heart support.

4) Indications and complications of temporary and long-term mechanical cardiac support.5) Pathophysiology of brain death and donor management. 6) Immunology of rejection and the management of immunosuppression.



Clinical Skills: 1) Be able to recognize and manage end-stage cardiac failure using medical therapy.2) Be able to understand the recommendation for the appropriate surgical therapy.3) Be able to manage postoperative complications in patients supported with mechanical

heart disease, including the important role of nutrition and infection prevention. 4) Be able to understand the management of immunosuppression and deal with its

complications.

Electrophysiology

Knowledge: 1) Principles of management of patients with dysrhythmias, especially postoperative atrial

fibrillation. 2) Pathophysiology and electrophysiology of atrial and ventricular dysrhythmias and the

pharmacology and indications for medical management. 3) Indications for implantation of pacemakers and automatic implantable cardioverters

[AICD].

Clinical Skills: 1) Be able to recognize and treat patients with dysrhythmias, especially postoperative atrial

fibrillation. 2) Be able to recommend the appropriate pacemaker device for implantation.3) Be able to recognize and recommend appropriate treatment for complications of

pacemakers, such as the pacemaker syndrome and infections.

Senior Adult Cardiac Surgery

General Objectives The senior resident should be able to assess, investigate, diagnose, manage clinically and surgically adult patients presenting with all the common cardiac surgical pathologies encountered in a tertiary and quaternary care hospital. At the completion of his/her rotation, the senior resident will be expected to be able to function at a consultant level and be capable of managing patients undergoing cardiac surgical procedures, and be knowledgeable about the pathophysiology behind their disease process, as well as all the complications and their management.

Specific Objectives Knowledge: 1) Basic Science:

The senior resident in Cardiac Surgery will fully understand all of the cardiac andvascular physiology as it applies to the disease process of his/her patients will have during the rotation.

Pathophysiology of atherosclerosis as it applies to the cardiac, vascular and cerebralsystems.

Pathophysiological mechanism of simple and complex atrial and ventriculararrhythmias.

Basic fluid and electrolyte and acid base balances, pathophysiology of extracorporealcirculation.



Hemodynamic parameters as they apply to normal and abnormal cardiac and vascularpathologies.

Cerebral metabolism under normal and hypothermic conditions.

Infectious processes as they apply to surgical wounds and cardiac valves.

Basic hemodynamic parameters as they apply to normal cardiac pathology, as well asto ventricular assist devices.

Basic principles of immunosuppression.

2) Cardiac Surgical Knowledge:

The senior resident will recognize the unique natural histories of adult cardiac surgicaldiseases.

The senior resident will understand and take an active part in the diagnosis, investigation and establishment of surgical indications for the following diseaseprocesses:o Coronary artery disease – stable, unstable.o Myocardial infarction and its mechanical complications, namely left ventricular

rupture, acute mitral regurgitation, ventricular septal defect, shock.o Aortic valve disease [insufficiency, stenosis, nicks in the acute, chronic or

endocarditis setting].o Pericardial disease as it applies to constrictive pericarditis, pericardial tamponade

or malignant effusions.o Mitral valve disease [regurgitation, stenosis, combined acute, chronic and

endocarditis].o Tricuspid valve disease [tricuspid regurgitation and stenosis either isolated or

combined with left sided valvular lesions].o Ascending aortic disease and arch disease, namely aneurysmal dilatation, acute

and chronic dissection, and extensive calcification.o Extracranial vascular disease as it applies to Cardiac Surgery.o Adult congenital disease.o Arrhythmia [pre-, peri- and post-operative, namely pacemaker, epicardial and

endovenous].o Surgical ablative procedures.o Percutaneous ablative procedures.o Automated implantable defibrillators.o Benign and malignant cardiac tumors [diagnosis, investigations and principles of

treatment (surgical and non-surgical)].o Clear understanding of how to interpret hemodynamic tracings, coronary

angiography, aortic angiography, cardiac Magnetic Resonance Imaging, as well asechocardiography.

The senior resident is expected to be working under the direction supervision of theattending staff, but will be functioning at a near consultant level with the highest levelof responsibilities in the perioperative management issues of all of the patients in theCardiac Surgery Service.

The senior resident will be involved with all of the elective and urgent consultationsoriginating from the Emergency Room, the Coronary Care Unit or the Intensive CareUnit.



Technical Skills: At the end of the surgical rotation, the senior resident will be able to perform in an independent or semi-independent fashion the following tasks:

Cannulation for extracorporeal circulation, either anatomic or extra-anatomical.

Harvesting of arterial [internal thoracic and gastro-epiploic arteries] and venous conduits [greater and lesser saphenous veins].

Appropriate setting up of all the operating field, cannulas and equipment for safeconduct of the operation.

Distal and proximal vein and arterial coronary anastomoses.

Establishment of a hemostatic shield at the completion of the procedure.

Full understanding of the prerequisites to safely wean a patient off extracorporealcirculation.

Interpretation of perioperative transesophageal echocardiography.

Replacement of the ascending aorta or the arch of the aorta, either with a tube graftor a composite valve conduit with re-implantation of the coronary buttons.

Replacement of the aortic valve, either with a bioprosthesis or mechanical prosthesis.

Good understanding of the application of stentless bioprostheses in the aortic position, as well as valve sparing aortic root reconstructions.

Tricuspid valve replacement or repair with an annuloplasty ring.

Mitral valve repair as it applies to implantation of an annuloplasty ring.

Good understanding of the principles of more complex mitral valve repairs, such as posterior quadrangular resection, chordal transfer, artificial chordae, etc.

Resection of left ventricular aneurysm either with linear exclusion or endocardialapproach.

Preparation of the surgical field for beating heart surgery.

Assistance in the performance of distal anastomoses on a beating heart.

Independent implantation of epicardial, atrial and ventricular pacemakers, as well as independent implantation of dual and single chamber endovenous pacemakers.

Implantation of endovenous defibrillators.

Transthoracic implantation of epicardial pacing electrodes.

Re-exploration for tamponade in postoperative cardiac surgery patients.

Performance of pericardial windows using either the subxiphoid or the thoracicapproach.

Insertion and excision of intraaortic balloon pump.

First assistance in the implantation of mechanical assist devices.

Cardiac transplantation.

TEACHING AND LEARNING



Structure

Teaching and learning are designed for delivery through various methods by mixing formal didactic lectures and self-learning processes through a structured and programmatic core education program:

Formal Teaching and Learning Activities:

Core specialty topics will be delivered as a basic science lectures and specialty topics

Universal topics

Practice-Based Learning (PBL):

Morning report case presentations

Morbidity and mortality review

Journal club

Case presentation

Grand round/guest speakers on core specialty topics

Work-Based Learning (WBL):

Daily round-based learning

On-call-based learning

Clinic-based learning

Workshops and courses

Tutorials

General Topics

Management of Fluid in Hospitalized Patients (R1)

Review physiological basis of water balance in the body.

Assess patient for hydration.

Recognize a patient with over- and underhydration.

Order fluid therapy as oral and IV.

Monitor fluid status and response to therapy.

Management of Electrolyte Imbalances (R1)

Review physiological basis of electrolyte and acid-base balance in the body.

Identify diseases and conditions that are likely to cause electrolyte imbalance.

Correct electrolyte and acid-base imbalance.

Perform careful calculation, checks and other safety measures while correcting acid-baseand electrolyte imbalance.

Monitor response to therapy.



Blood Transfusion (R1)

Review the different components of blood products available for transfusion.

Recognize the indication and contraindication of blood transfusion.

Discuss the benefits, risk, and alternative to transfusion.

Undertake consent for specific blood product transfusion.

Perform steps necessary for safe transfusion.

Develop understanding of special precaution and procedure necessary during massive transfusion.

Recognize transfusion-associated reactions and immediate management.

Acute Pain Management (R2)

Review the physiological basis of pain perception.

Proactively identify a patient who might be in acute pain.

Assess patient with acute pain.

Apply pharmacological and non-pharmacological modalities for acute pain management.

Provide adequate pain relief.

Safe Drug Prescribing (R3, R4)

Recognize importance of safe drug prescribing in health care.

Describe the various adverse drug reactions with examples of commonly prescribed drugs that can cause such reaction.

Apply principles of drug interaction, drug food interaction, drug disease interaction.

Apply principles of prescribing drug in special situation such as renal impairment.

Apply principles of prescribing drugs in elderly, pediatric and in pregnancy.

Promote evidence-based cost effective prescribing.

Discuss ethical and legal framework governing safe drug prescribing in Saudi Arabia.

Sepsis, SIRS, DIVC (R1-R3)

Explain the pathogenesis.

Identify patient-related and non-patient-related predisposing factors of sepsis.

Recognize patient at risk of developing sepsis.

Describe the complications of sepsis.

Apply the principles of patient management.

Describe the prognosis.

Hospital Acquired Infection (R1- R3)

Discuss the epidemiology of HAI with special reference to HAI in Saudi Arabia.

Recognize HAI as one of the major emerging threats in healthcare.

Identify the common source of HAI.

Describe the risk factors of common HAI MRSA, VRE, and CLABSI.

Identify the role of health workers in prevention of HAI.

Determine appropriate pharmacological and non-pharmacological measure in thetreatment of HAI.

Propose a plan to prevent HAI in the workplace.



Role of Doctors in Death and Dying (R7)

Recognize important role a doctor can play during a dying process.

Provide emotional, as well as physical, care to a dying patient and family.

Provide appropriate pain management in a dying patient.

Identify suitable patient and refer to patient to palliative care services.

Ethical Issue: Transplant/Organ Harvesting/Withdrawal of Care (R7)

Apply key ethical and religious principles governing organ transplantation and withdrawal of care.

Be familiar with the legal and regulatory guideline regarding organ transplantation andwithdrawal care.

Counsel patients and families in the light of applicable ethical and religious principles.

Guide patients and families to make decision.

Ethical Issues: Treatment Refusal, Patient Autonomy (R7)

Predict situations where a patient or family is likely to decline prescribed treatment.

Describe the concept of rational adult in the context of patient autonomy and treatmentrefusal.

Analyze key ethical moral and regulatory dilemmas in treatment refusal.

Recognize the importance of patient autonomy in the decision making process.

Counsel patient and families declining medical treatment in the light of the best interest ofpatient.

Preoperative Assessment (R1-R3) At the end of the Learning Unit, you should be able to:

Describe the basic principles of preoperative assessment

Perform preoperative assessment in an uncomplicated patient with special emphasis on o General health assessmento Cardiorespiratory assessmento Medications and medical device assessmento Drug allergy

Categorize patients according to risks

Postoperative Care (R1-R3) At the end of the Learning Unit, you should be able to:

Devise a postoperative care plan including monitoring of vitals, pain management, fluid management, medications, and laboratory investigation

Hand-over the patients properly to appropriate facilities

Describe the process of postoperative recovery in a patient

Identify common postoperative complications

Monitor patients for possible postoperative complications

Institute immediate management for postoperative complications



Management of acute chest pain (R4) At the end of the Learning Unit, you should be able to:

Triage and categorize patients

Identify patients who need prompt medical and surgical attention

Generate a preliminary diagnosis-based history and physical examination

Order and interpret urgent investigations

Provide appropriate immediate management to patients

Refer the patients to next level of care, if needed

Management of acute breathlessness (R4) At the end of the Learning Unit, you should be able to:







Management of hypotension and hypertension (R4) At the end of the Learning Unit, you should be able to:







ECG Interpretation and response (R3)

Interpretation of ECG (rate, rhythm, PR interval, QRS duration, ST segment, morphology, T wave morphology, U wave and QT interval).

Identify the cause and treat accordingly.

Chest tube (CT) insertion/removal (R3, R4)

Knowledge of different sizes of chest tube and pigtails.

Technique of CT insertion.

Removal of CT (drainage and duration).

Identify the complications and management.

Wound care (R1, R2)

Knowledge of wound care management.

In case of infection, identify if superficial or deep (deep subcutaneous, osteomyelitis andmediastinitis).

Manage accordingly.



Harvesting vessels (R4)

Knowledge of detailed anatomy of possible conduits (veins and arteries – radial artery andIMA).

Proper technique of harvesting these vessels.

Preservation in proper solution (vein and artery).

Suturing technique (R1-R3)

Knowledge of different types of suture materials.

Knowledge of different suturing techniques (suture techniques: interrupted sutures andcontinuous sutures; knot-tying technique: one-handed knot, two-handed knot andinstrument ties).

Valve surgery technique (R4-R7)

Knowledge of different valve repair techniques.

Types of valves (tissue, mechanical, Ross, conduits and homograft).

Minimally invasive techniques.

Robotic-assisted techniques.

TAVI

Vascular anastomosis (R4-R7)

Knowledge of different vascular anastomotic techniques (end-to-side, side-to-side, and end-to-end anastomosis).

Knowledge of repair technique of injuries of conduits (veins and arteries).

Cardiac Catheterization (R2)

Knowledge of standard views of coronary system and interpretation.

Information obtained from right and left heart catheterization (RA pressure, RV pressure,PA pressure, PCW pressure and LVED pressure).

Central Line Insertion (R2)

Technique of central line insertion.

Knowledge of different sizes of central lines.

Complications after insertion and management.



Cardiac Surgery City Wide Curriculum

Topic

Fundamentals

Surgical Anatomy of the Heart

Cardiac Surgical Physiology

Cardiac Surgical Pharmacology

Pathology of Cardiac Surgery

Cardiac Surgical Imaging

Risk Stratification and Comorbidity

Perioperative Care

Preoperative Evaluation for Cardiac Surgery

Postoperative Care of Cardiac Surgery Patients

Late Complications of Cardiac Surgery

Intraoperative Care

Cardiac Anesthesia

Extracorporeal Circulation: Perfusion System, The Response of Humoral, Organ Damage

Myocardial Protection

Temporary Mechanical Circulatory Support

Ischemic Heart Disease

Myocardial Revascularization with Percutaneous Devices

Myocardial Revascularization with CABG, on-pump and off-pump

Minimally Invasive Myocardial Revascularization

Surgical Treatment of Complications of Acute Myocardial Infarction:

Free Wall Rupture

Postinfarction Ventricular Septal Defect

Acute Ischemic Mitral Regurgitation

Left Ventricular Aneurysm

Coronary Artery Reoperations

Aortic Valve Disease

Options for Aortic Valve Replacement: Bioprosthesis, Metallic, Stentless, Homograft

Aortic Valve Repair and Aortic Valve–Sparing Operations

Minimally Invasive Aortic Valve Surgery

Mitral Valve Disease

Options for Mitral Valve Replacement

Mitral Valve Repair

Minimally Invasive Mitral Valve Surgery

Other Valvular Heart Disease

Tricuspid Valve Disease, Multiple Valve Disease, Valvular and Ischemic Heart Disease

Medical Treatment of Endocarditis

Surgical Treatment of Endocarditis



Topic

Diseases of the Great Vessels

Management of Aortic Dissection

Management of Aortic Aneurysms

Endovascular Treatment of Aortic Diseases

Other Cardiac Operations

Surgical & Interventional Therapy for Atrial Fibrillation

Pericardial Disease

Cardiac Neoplasms

Transplant and Circulatory Support

Heart & Heart-Lung Transplantation

Long-Term Mechanical Circulatory Support

Non-transplant Surgical Options for Heart Failure

Congenital Heart Disease

PDA, ASD, VSD

Subvalvular, valvular and supravalvular aortic stenosis

Interrupted aortic arch, aortic coarctation

Tetralogy of Fallot (with Pulmonary Stenosis, with Pulmonary Atresia)

Double Outlet RV

Anomalies of the Coronary Arteries

Hypoplastic Left Heart Syndrome

Single Ventricle

Total Anomalous Pulmonary Venous Drainage

Transposition of the Great Arteries, Congenitally Corrected Transposition of the Great Arteries

AV Canal Defect

Truncus Arteriosus

ASSESSMENT


ASSESSMENT

Evaluations and assessments throughout the program are conducted in accordance with the Commission’s training and examination rules and regulations. The process includes the following steps.

Annual Assessment

Continuous Appraisal

This assessment is conducted toward the end of each training rotation throughout the academic year and at the end of each academic year as a continuous assessment in the form of a formative and summative evaluation.

Formative Continuous Evaluation

Help residents identify their strengths and weaknesses and target areas that needwork.

Help faculty recognize where residents are struggling and address problems immediately.

To fulfill the CanMEDS competencies based on the end-of-rotation evaluation, theresident’s performance will be jointly evaluated by relevant staff for the followingcompetencies:

1. Performance of the trainee during daily work.

2. Performance and participation in academic activities.

3. Performance in a 10- to 20-min direct observational assessment of trainee–patient

interactions. Trainers are encouraged to perform at least one assessment per clinical

rotation, preferably near the end of the rotation. Trainers should provide timely and

specific feedback to the trainee after each assessment of a trainee–patient encounter.

4. Performance of diagnostic and therapeutic procedural skills by the trainee. Timely and

specific feedback for the trainee after each procedure is mandatory.

5. The CanMEDS-based competencies end-of-rotation evaluation form must be completed

within 2 weeks after the end of each rotation (preferably in electronic format) and signed

by at least two consultants. The program director will discuss the evaluation with the

resident, as necessary. The evaluation form will be submitted to the Regional Training

Supervisory Committee of the SCFHS within 4 weeks after the end of the rotation.

6. The assessment tools used, can be in the form of an educational portfolio (i.e., monthly

evaluation, rotational Mini-CEX*, long case assessment CBDs,** DOPS,*** and MSF****).

7. Academic and clinical assignments should be documented on an annual basis using the electronic logbook (when applicable). Evaluations will be based on accomplishment of the minimum requirements for the procedures and clinical skills, as determined by the program.

*Clinical evaluation exercises**Case-based discussions ***Direct observation of practical skills ****Multisource feedback

ASSESSMENT


Summative Continuous Evaluation This is a summative continuous evaluation report prepared for each resident at the end of each academic year. The report may also involve the result of clinical examination, oral examination, objective structured practical examination (OSPE), objective structured clinical examination (OSCE), and international in training evaluation exam

End-of-Year Examination

The end-of-year examination will be limited to R1, R2, R3, R4, R5 and R6 . The number of exam items, eligibility, and passing score will be in accordance with the Commission’s training and examination rules and regulations. Examination details and blueprints are posted on the commission website: www.scfhs.org.sa

Annual Promotion Annual promotion depends on obtaining satisfactory evaluation in rotation in that year, in addition to passing the end-of-year exam. An average of 60% score in the end-of-year examination and continuous assessment with a minimum of 50% in each is required for passing.

Principles of Cardiac Surgery Examination (Saudi Board Examination: Part I)

This written examination, which is conducted in multiple choice question formats, is held at least once a year. The number of exam items, eligibility, and passing score will be in accordance with the Commission’s training and examination rules and regulations. Examination details and blueprints are published on the commission website: www.scfhs.org.sa

Final In-training Evaluation Report (FITER)/Comprehensive Competency Report

(CCR)

In addition to approval of the completion of clinical requirements (resident’s logbook) by the local supervising committee, FITER is also prepared by program directors for each resident at the end of his or her final year in residency (R7). This report may also involve clinical examinations, oral examinations, or other academic assignments.

Final Cardiac Surgery Board Examination (Saudi Board Examination: Part II)

The final Saudi Board Examination comprises of two parts, a written examination and a clinical examination.

Written Examination This examination assesses the trainee’s theoretical knowledge base (including recent advances) and problem-solving capabilities with regard to the specialty of Cardiac Surgery. It is delivered in multiple choice question formats and held at least once a year. The number of exam items, exam format, eligibility, and passing score will be in accordance with the Commission’s training and examination rules and regulations. Examination details and blueprints are published on the commission website: www.scfhs.org.sa




ASSESSMENT


Clinical Examination This examination assesses a broad range of high-level clinical skills, including data collection, patient management, communication, and counseling skills. The examination is held at least once a year, preferably in an OSCE format in the form of patient management problems (PMPs). The exam eligibility, format, and passing score will be in accordance with the Commission’s training and examination rules and regulations. Examination details and blueprints are published on the commission website: www.scfhs.org.sa

Certification

Certificates of training completion will only be issued upon the resident’s successful completion of all program requirements. Candidates passing all components of the final specialty examination are awarded the “Saudi Board in Cardiac Surgery ” certificate.


REFERENCES


REFERENCES

1) Cardiac Surgery by Kirklin & Barratt-Boyes. 4th edition 2013.2) Sabiston and Spencer’s Surgery of the Chest by Frank Selke. 8th Edition 2010.3) Clinical Anatomy by Richard Snell. 7th Edition 2004.4) Textbook of Medical Physiology by Guyton & Hall. 10th edition 2000.5) Lippincott’s Pharmacology. 3rd edition 2006.6) Manual of Peri-operative Care in Adult Cardiac Surgery by Robert M. Bojar. 3rd Edition

2005. 7) Glenn’s Thoracic and Cardiovascular Surgery. 6th edition 1996.8) Comprehensive Surgical Management of Congenital Heart Disease by Richard Jonas. 2nd

Edition 2014.9) Pediatric Cardiac Surgery by Constantine Mavroudis. 4th Edition 2013.10) Marino’s The ICU Book by Paul Marino. 4th Edition 2013.

APPENDICES


APPENDICES

APPENDICES


Training Sites

Number of Candidates Accepted

The Cardiac Surgery Training Program will be a joint program (i.e. applications will be through the Saudi Medical Council for Health Specialties and candidate selection, number and rotations among approved Centers will be determined by the Cardiac Surgery Scientific Board). Number of candidates per center will be according to number of surgeries performed [One candidate for every 250 adult & 150 Pediatric (400) operations]. The final quota is to be determined by the accreditation committee.

The center must be in operation for 3 years since the start of the Cardiac Surgery Training Program.

Qualified Centers or Hospitals for Training

The basic general surgical training must be done in a hospital which is recognized by theSaudi Board of General Surgery.

To be recognized for training in Adult Cardiac Surgery, the Center must perform at least250 adult cases annually.

To be recognized for training in Pediatric Cardiac Surgery, the Center must perform at least150 cases annually. However, it is not necessary that the Center be recognized for both.

The Training Center must have highly skilled staff with at least 50% of them having morethan 5 years of experience as Consultant Cardiac Surgeons. The center should be morethan 3 years old.

There should be a wide variety of cases covering different cardiovascular pathologies.Periodic evaluations of the Centers by the Cardiac Surgery local committee should beconducted.

The Center should have highly skilled, well trained staff in the different related cardiacspecialties (Cardiologists, Cardiac Anesthetists and Intensivists). The Center should havewell-equipped Operating Rooms, Cardiac Intensive Care Units (Surgical ICU, Medical CCU, Neonatal ICU and Pediatric ICU, Cardiac support facilities; IABP, LVAD, etc.),Catheterization Labs, Echocardiography Labs (2D and 3D Echocardiography and TEE),Infection Control Service, Training and Research Department, Information Technology Department with a Medical Library, Total Quality Management Department. Preferablythe Center should have accessible CT Angio, MRI, Nuclear Scanning, and Cardiac AssistDevices (LVAD, RVAD, etc.), ECMO, Cardiac Rehab, Social Services, Cardiac DietitianService, with the Center having good access to consultation with other services andmedical specialties (such as Diabetes and Endocrinology, Nephrology, Neurology, etc.)

Responsibilities of the Supervising Consultants

The Supervising Consultants:

Must have the Board or Fellowship or equivalent in Cardiac Surgery and at least 3 years ofexperience as a Consultant Cardiac Surgeon.

Shall participate and supervise the teaching of the candidates (preoperative, operative andpostoperative management of the patient) by giving lectures, delegating selected surgerycases to the candidates in the operating room and taking him/her through all the operativesteps.

APPENDICES


Shall encourage the candidates to participate in Journal Clubs, Morbidity & Mortality andall academic and educational activities.

Are to conduct performance evaluation sessions (every 3 months) to review thecandidates’ work performance and complete a special evaluation form for such a program.

Are to conduct disciplinary meetings when appropriate.

Shall supervise and assist in cardiothoracic researches, presentations and publications.

Shall motivate the candidate by delegating responsibilities in patient management.

Will monitor the candidate’s demeanor (manner, conduct, behavior, character,deportment, performance, appearance, bearing, attitude, disposition, image, expression).

Are to arrange regular meetings with the candidates to provide feedback on performanceand work with them towards improving their standards.

Must verify the candidate’s logbook and countersign it.

Are to ensure that the candidate is exposed to a wide variety of cases covering differentcardiovascular pathology.

Responsibilities of the Program Directors

The Program Directors:

Must have Board or Fellowship or equivalent and at least 6 years of experience as aConsultant Cardiac Surgeon.

Are responsible for selecting the candidates.

Shall conduct continuous and periodic evaluation of candidates by regular assessments andexams.

Shall monitor the supervising consultants and ensure their adherence to the trainingprogram.

Will arrange six monthly meetings with the Supervising Consultants and the candidates, tomonitor their performance, listen to their grievances and act as mediator in problem-solving.

Should inspect and review the candidate’s training program on a regular basis and make suggestions for improvement.

Should help the candidate in sorting out any legal or logistic issues.

Are to ensure that trainees get increasing levels of responsibility and experienceappropriate to their level of training.

Shall verify the candidate’s logbooks.

Are to provide an adequate level of academic and educational activities for the candidatesby organizing regular symposiums and meetings and inviting distinguished national and international speakers and surgeons.

Sponsorship

Training should be funded by the candidate’s Center sponsoring him for training. The candidate should have a letter of sponsorship from his own Center.

otr & str - cardiac surgery (2004) eng

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